community healthcare - operations plan 2019 · patients and service users, to be more responsive to...

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South East Community Healthcare - Operations Plan 2019

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Contents

Foreword from the Chief Officer …………………………………………………………………….. ........................ 3

1. Introduction ………………………………………………………………………………………………. ......................... 6

Our Population……………………………………………………………………………………………. ....................... 6

Reform and Transformation ………………………………………………………………………… ..................... 11

2. Clinical Quality and Patient Safety ………………………………………………………………. ..................... 14

3. Health & Wellbeing ……………………………………………………………………………………. ...................... 20

4. Primary Care & Social Inclusion …………………………………………………………………… ..................... 30

5. Mental Health ……………………………………………………………………………………………. ...................... 52

6. Disabilities ………………………………………………………………………………………………… ....................... 60

7. Older Persons and Palliative Care………………………………………………………………… ..................... 70

8. Workforce ………………………………………………………………………………………………………………. .......... 79

9. Finance & Value Improvement Programme…………………………………………………………………. ...... 86

Appendices……………………………………………………………………………………………………………………......... 91

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Foreword from the Chief Officer

I am pleased to present our South East Community Healthcare Delivery Plan for 2019.

South East Community Healthcare is responsible for providing community health and social care services to a population of 510,333 within the South Eastern counties of Waterford, Wexford, South Tipperary, Carlow and Kilkenny. We are committed to ensuring that services delivered in the South East are of high quality safe care, with equitable access and distribution within the resources available.

This South East Community Healthcare Delivery Plan 2019 sets out the type and volume of health and personal social services to be provided in community settings in the South East during 2019 within the funding available. It also includes developmental actions that will be undertaken in 2019 to continue to improve and expand upon service delivery. Our plan incorporates priorities as set out in the HSE National Service Plan 2019 and the HSE National Community Operations Plan and our own local strategic priorities.

Within this plan, our services are outlined within the care groups of Primary Care, Health and Wellbeing, Older Persons, Disability, and Mental Health. These services will be delivered using an integrated approach to provide a sustainable, high quality safe and effective healthcare that meets the needs of our population. Integration between our care groups, as well as with our partners such as acute hospitals and voluntary organisations, will continue to be the main foundation block to deliver service user centred care.

While this Delivery Plan sets out how services will be provided over the coming year within our catchment area for each of our key care-groups, South East Community Healthcare will continue to apply a multi-year approach to planning key service improvements for our community.

A key priority for 2019 will be to maintain appropriate capacity in our services. South East Community Healthcare continues to deliver services in a challenging environment of population growth, increasing demand for our services, increased public expectation, an ageing population, and a rise in Governance and Compliance obligations. Meeting the health needs of our population within the funding available will present an on-going and significant management challenge during 2019.

Our dedicated teams will continue to promote and implement service improvement and innovation opportunities throughout our services during 2019 and will strive to foster a culture that can continuously improve the quality of healthcare for our service users.

The Sláintecare Report (2017) and Sláintecare Implementation Strategy (2018) signal a new direction for the delivery of health and social care services in Ireland. South East Community Healthcare welcomes the focus on moving to a community-led model, which can provide

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local populations with access to a comprehensive range of non-acute services at every stage of their lives. This can enable our healthcare system to provide care closer to home for patients and service users, to be more responsive to needs and deliver better outcomes, with a strong focus on prevention and population health improvement.

An important feature of the delivery of safer services is that of governance and accountability, and our teams will be working to key performance indicators as set out in this plan. The delivery of the plan will be underpinned by the HSE Accountability Framework and through the ongoing strengthening of governance arrangements.

Key service priorities for South East Community Healthcare in 2019 will include:

Continued implementation of our Healthy Ireland Plan with a sustained focus on achieving the high level goals of Healthy Ireland and improving the health and wellbeing of our population.

Reducing inequalities in health and improving outcomes for the most vulnerable in our area, and enhancing participation of socially excluded groups and communities in health services.

Continue to build on success of our Community Intervention Teams to facilitate increased volume of complex hospital avoidance and early discharge cases across Carlow/Kilkenny, South Tipperary and Waterford.

Develop an overarching service improvement initiative to address the needs of children and young people including promotion, prevention, early intervention, primary, disability and mental health services. We will develop a service improvement plan that addresses the needs of children and young people across the care spectrum and in particular implement the National Policy on Access to Services for Children and Young People with Disability and Developmental Delay within available resources.

Continue to improve quality, safety, access and responsiveness of primary care services to support the decisive shift of services to primary care.

Continue with the implementation structures for local action plans within our Mental Health Services aligned to National Connecting for Life implementation framework with the objective of reducing suicide rates in our community.

Continued development of a recovery focused community mental health service will be an ongoing priority for during 2019. This work will be supported by the implementation of the Service Reform Fund Project and roll out of Advancing Recovery Initiatives. South East Community Healthcare will also work with the Department of Housing, Planning and Local Government regarding the implementation of the National Housing Strategy as it relates to South East Community Healthcare residential services.

Our Mental Health Service will continue with the implementation of the ‘Best Practice Guidance Framework’ to ensure better governance in planning and measuring improvement, and identifying and addressing gaps. Work commenced in our approved centres in 2018 and this framework will roll out to other service areas in 2019.

Progress implementation of Time to Move on from Congregated Settings by supporting a further 38 people with disabilities to transition to homes in the community in 2019.

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Progress implementation of New Directions national policy on the provision of day

services for people with disabilities and strengthen the quality of day service provision

throughout the South East.

The implementation of the new HSE Incident Management Framework will provide a consistent and effective response to the management of incidents and support those affected by the incident.

Continue to further develop and implement the Integrated Care Programmes for Older Persons (ICPOP) in conjunction with our acute hospital partners.

Completion of new state of the art Regional Specialist Inpatient Unit & Day Service in Palliative Medicine at University Hospital Waterford in line with the implementation of HSE Palliative Care Services Three Year Development Framework (2017 – 2019).

Continue to develop our workforce to ensure the delivery of a person-centred social care model of service.

The single Funding Model of Home Support commenced in 2018 will be further embedded in 2019 with a particular focus on strengthening governance, management capability, quality, and reliability.

Implement the health actions, identified as a priority in 2019, in Rebuilding Ireland Action Plan for Housing and Homelessness, 2016 and Housing First National Implementation Plan, 2018 - 2021, in order to provide the most appropriate Primary Care, specialist addiction, and mental health services for homeless people.

I wish to thank our staff for their hard work and commitment to ensuring that quality social care, mental health and primary care services are delivered to the people of the South East. Their support and dedication is deeply appreciated and is making a real difference to the lives of those that depend on us in counties Carlow, Kilkenny, South Tipperary, Waterford and Wexford.

Kate Killeen-White Chief Officer South East Community Healthcare

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Section 1 Introduction

1. Introduction Our Delivery Plan has been prepared in response to HSE National Service Plan 2019 and the funding allocation and associated requirements and conditions set out in the Department of Health’s Letter of Determination. It sets out community healthcare services to be provided in County Waterford, Wexford, South Tipperary, Carlow and Kilkenny by type and volume within the funding resources provided to the area for 2019. It is recognised that 2019 will be another challenging year for healthcare delivery in Ireland. South East Community Healthcare continues to deliver services in an environment where the population is growing, the number of people seeking to access services is higher than before and where public expectations for quality of services continue to increase. Balancing demands and needs within the funding available will be an on-going and significant management challenge in 2019 and may impact on the successful delivery of this plan. We are determined to address these challenges through a constant focus on improvement and innovation. As a Community Health Organisation (CHO) we will continue to work in close partnership with service users and their families, always seeking opportunities to improve the service user experience of care in the south east, and support staff in the delivery of these services.

During 2019, we will continue all efforts towards enhancing the health of our population

and enabling everyone to optimise their own health and wellbeing. Our CHO will prioritise

initiatives that can prevent and reduce ill health; improve access to our services; and

maximize all opportunities to further improve integration of healthcare delivery in our

area. This plan places strong emphasis on achieving further improvement in integrated

care across our community services and between Community Healthcare and Acute

Hospitals.

We will continue to prioritise chronic disease management through 2019 with almost three

quarters of all deaths in Ireland due to three chronic diseases: cancer, cardiovascular

disease, and respiratory disease.

Our Population

According to the 2016 Census, the total population of our catchment area is 510,333

people, a net increase of 12,755 (+2.6%) since the previous Census in 2011. The greatest

increases were in the older age groups with 74,302 people now aged 65 years and older.

This age group has grown by 11,481 since 2011 Census. The greatest decreases in

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population groups were in the younger age groups, particularly those aged 25-34 years

(-11,447). Source: CSO preliminary census 2016 and census 2011

Life Expectancy and Health Status

The Department of Health in Ireland: Key Trends, 2018 shows that life expectancy in Ireland

has increased by almost two and a half years since 2006, with male life expectancy

consistently higher than the EU average throughout the last decade.

Much of this increase in life expectancy is due to significant reductions in major causes of

death such as circulatory system diseases and cancer. This decrease is particularly strong

for mortality rates from stroke (-39%), breast cancer (-16%), suicide (-26%) and pneumonia

(-39%). The overall mortality rate has reduced by 14.9% since 2008.

Life expectancy in the South East is similar to national figures with women at just over 83

years and men at 79.3. The greatest gain in life expectancy has been achieved in the older

age groups, particularly those aged 65-74 (+7,501) reflecting decreasing mortality rates

from major diseases.

Healthy Childhood

Although our national birth rates are decreasing our child population aged 0-17 years, is

above the EU average (Ireland 26% and EU is 18.8%) (Department of Health and Children

and Youth Affairs 2014). The variation in our age profile presents challenges in responding

to health needs and will require our service planning to reflect different population health

needs.

Within the South East our aim is to ensure children living in the South East experience a

healthy childhood. Challenges to achieving our aim are highlighted in the 2018, Child Health

Profiles and include the following:

Infant Mortality Rates

Waterford County had one of the highest infant mortality rates in the country in 2017

(6.0/1,000 vs 2.8/1,000 nationally).

The 5 year standardised child mortality rate (2013-17) in Carlow was the highest in the

country (5.0/100,000 vs 2.7/100,000 nationally). This compares with their neighbouring

County Kilkenny which had one of the lowest child mortality rates in 2017 and 5 year

standardised child mortality rates (2013-17) in the country (0.8/100,000 vs 2.4/100,000

nationally and 1.5/100,000 vs 2.7/100,000 nationally).

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Carlow had lowest proportion of low birth-weight births in the country (3.1% vs 5.5%

nationally).

Immunisation Rates

We know the importance of immunisation for children and our community medical doctors,

registered public health nurses and administrative staff who are continuously working to

support an increase in uptake rates in South East Community Healthcare. We are aware of

the challenges that staff face and although progress has been made, we still have a way to

go in achieving national targets.

In 2017 Carlow/Kilkenny (95.7%), Tipperary South (96.2%) and Wexford (95.1%) met

the 6-in-1 vaccination at the 24 month national target. However, all areas in South

East Community Healthcare had higher uptake rates than the national average by 24

months.

In 2017 none of our areas in South East Community Healthcare met the 95% uptake

target for the MMR vaccination at 24 months, although it was very close in

Carlow/Kilkenny (94.3%). However, all areas in South East Community Healthcare

had higher uptake rates in 2017 than the national average.

In 2017 Carlow/Kilkenny had one of the highest uptake rates in the country for the

MMR in Junior Infants (95.2%). This was the only area in South East Community

Healthcare to meet the national target.

In 2016/2017 Wexford had one of the lowest uptake rate of the HPV vaccination in in

the country (41.6% vs 51.0% nationally). However, the update rate of the HPV

vaccination by girls in Carlow/Kilkenny and Waterford was higher than the national

uptake rate.

Breastfeeding

In 2017, the rate of breastfeeding on discharge from hospital was significantly below the

national average in Carlow, Tipperary, and Wexford (55.1%, 49.9%, 50.8%, respectively vs

59.9% nationally).

Chronic Disease

We know that the major chronic diseases; diabetes, cardiovascular and respiratory disease

will increase by 20% -30% in the next five years. Chronic disease accounts for 76% of

deaths, 80% of GP consultations, 40% of admissions, 75% of bed days and 55% of hospital

expenditure in Ireland.

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Heart disease and diabetes can deprive people of up to 8 years of life and 19 years of a

healthy life.

108,738 is the estimated amount of people living within the South East with a chronic

condition.

People living with a chronic condition such as diabetes, asthma, COPD or heart disease

manage their medicines, their behaviours and their emotions every day. Self-Management

Support aims to help and support the population to manage their chronic conditions better.

In January 2019, we launched our South East Directory of Services and Programmes for

Adults with Diabetes, Heart Conditions, Stroke, COPD and Asthma.

Making Every Contact Count

Making Every Contact Count is central to healthcare reform. It is based upon the up-skilling

of all front line staff to use a behavioural change model to support those they are in contact

with to eat well, get active, rethink their drinking and quit smoking. In 2019, we will be

implementing Making Every Contact Count in five learning sites across the South East.

Health Inequalities

It is well established that there is a strong link between poverty, socio-economic status and

health.

As the following table shows, each county in the South East and South East Community

Healthcare as a whole has a higher proportion of population categorised as disadvantaged

to some extent, and a smaller proportion categorised as ‘affluent’ to ‘extremely affluent’

than national averages. As shown below, Wexford has the highest level of disadvantage in

South East Community Healthcare.

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Refugees and Asylum Seekers

South East Community Healthcare has five Direct Provision Centres (DPC) for asylum seekers

within its geographic remit; two in Waterford City, two in Tramore, Co Waterford and one in

Carrick-on-Suir, Co. Tipperary. The total number of asylum seekers residing in the South East

can be greater than 500 people at any one time, each with varying health needs.

There is also an Emergency Reception and Orientation Centre (EROC) in Clonea, Co.

Waterford for up to 120 Programme Refugees.

In addition to these, refugee resettlement programmes are now in place in Waterford,

Wexford, Carlow and Kilkenny for those that have been granted refugee status.

In order to support the health needs of these groups, we provide an “In-reach Primary

Healthcare Model of care”. We developed this initially from our learning in providing

healthcare education and support within the EROC.

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This model includes a Health Education Toolkit which includes translated materials

regarding health orientation (information and access), Healthy Eating / Diet, Information

about Exercise, Over the Counter Medication, Self Care (colds and flu etc) based on “Under

the Weather.ie” and trauma information and education.

Homelessness

Across Community Healthcare there is strong commitment to improving the quality of care

and improvement of homelessness services. This includes work being undertaken by

frontline teams and larger developments and improvement programmes at group,

organisation and system level. Improving quality is everybody’s business and to achieve real

and sustained improvements we must find new and better ways to achieve the outcomes

that will best meet patient needs. Community Healthcare is committed to providing care

that is person centred, effective, and safe and which leads to better health and wellbeing.

Section 2 of this plan details the specific actions that will be taken to progress our clinical

and service quality improvement strategy.

Travellers and Roma

A similar percentage of the population in the South East are Travellers (0.7%) compared to

the National average (0.7%). Nearly four thousand (3,728) live in South East Community

Healthcare, which is approximately 12% of the national Traveller population (30,987). The

Traveller population has a shorter life expectancy than the general population, over 11 years

shorter for Traveller women and 15 years shorter for Traveller men (Traveller Report 2014).

Worryingly, this leads to a mortality rate far greater than the general population (three

times greater for Traveller women and four times greater for Traveller men). Our two

Traveller Health Projects in County Wexford will be part of Making Every Contact Count

Learning Sites in 2019.

Reform and Transformation

Sláintecare Report (2017) and Sláintecare Implementation Strategy (2018) signal a new

direction for the delivery of health and social care services in Ireland and offers a framework

within which the HSE will focus on transforming health services over the coming decade.

South East Community Healthcare will welcome this focus on moving to a community-led

model as an opportunity to enable our healthcare system to provide care closer to home for

patients and service users, and to be more responsive to needs and deliver better

outcomes, with a strong focus on prevention and population health improvement.

South East Community Healthcare is committed to the principle of transferring care from

acute and congregated settings, to more appropriate community and home-based settings.

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Our aim over time is to maximise all available opportunities to meet the vast majority of the

population’s health and social care needs in local settings. This goal is reflected throughout

our plan and includes initiatives which support collaboration and integrated working across

professions, acute and primary and community service settings and across all localities.

Portfolio Management Office (PMO)

The PMO provides a consistent and best practice approach to project and programme

management. It works to ensure that all change is appropriately planned and implemented

in a managed and systematic way and that South East Community Healthcare resources and

expertise are aligned to service delivery priorities and that these priorities are delivered in

defined and measurable ways.

At project level it strives to ensure a consistent and best practice project management

approach, providing an environment where projects can be run successfully. At programme

level it emphasises the co-ordinating and prioritising of resources across projects and

managing links between the projects. It ensures that a group of related projects are

managed in a co-ordinated manner to obtain benefits and control not available from

managing them individually.

The aim of our PMO is to support and accelerate the realisation of service improvement

reforms through the delivery of local and national initiatives as set out in our Delivery and

Operational Plan for 2019 and through the realisation of the intent of CHO Report

(Community Healthcare Organisations – Report and Recommendations of the Integrated

Service Area Review Group’, published in October 2014), the SláinteCare Report (2017), and

the SláinteCare Implementation Strategy (2018). The PMO within South East Community

Healthcare will support this body of work throughout 2019.

The main functions of the PMO are:

Methodology: Act as a central point for the approved project methodology, lessons learned

and best practice to enable successful delivery of programme and project work to agreed

time, cost and quality requirements.

Governance: Drive and oversee health service improvement at a local level on behalf of the

Project Sponsor and ensure that the Portfolio Steering Group, project working groups and

project teams have the appropriate information to make necessary change decisions.

Integration: Connect programmes and projects across the HSE; identify interdependencies

and risks; network and promote the programme efforts throughout the health system.

Delivery Support: Assist project teams to deliver on an agreed scope of work by providing

advice, suggestions and developing required team competencies.

Oversight and Traceability: Collate and report programme and project status reports;

manage project documentation, including risk registers, schedules, incident logs, benefits

plan etc., monitor and review programme and project performance.

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Risks to the delivery of Operational Plan 2019

South East Community Healthcare is committed to ensuring best possible healthcare outcomes are achieved for our service users, within the resources available to us. Meeting the health needs of our population within the funding available will present an on-going and significant management challenge during 2019. As mentioned in my Foreword, we continue to operate in a challenging environment of population growth, increasing demand for our services, increased public expectation, an ageing population, and a rise in Governance and Compliance obligations.

There are a number of risks to the successful delivery of our 2019 Plan and particular focus will be required to mitigate risk in the following areas:

Potential additional demand for services beyond funded levels. This will be impacted by multiple factors including population growth and key demographic changes such as ageing population, increased numbers of people living with a disability, and increase in incidence of chronic disease.

Meeting the regulatory requirements in public long-stay residential care facilities and the disability sector which must be responded to within the limits of the revenue and capital funding available.

Level of changing needs and requirement for emergency placements in Disability Services and Mental Health.

Responding to additional service pressures which will arise during the winter period in relation to hospital, community and primary care services.

Requirement to provide complex paediatric discharges within Primary Care.

Impact of Brexit.

Progressing at scale and pace the required transformation agenda, in the context of resources available.

Responding to unplanned and unforeseen events (e.g. adverse weather / other

environmental events), in the absence of a contingency fund in 2019.

Responding adequately within available funding to support delivery of key service

developments and expansion in community services.

Complying with the General Data Protection Regulation requirements.

Effectively managing our workforce, including recruitment and retention of a highly

skilled and qualified workforce, delivering a reduction in overtime and the use of agency

personnel and staying within our pay budget.

Control over pay and staff numbers while seeking to deliver on key service delivery targets and achieve compliance with our regulatory requirements.

Supporting information driven health care within the limitations of our clinical, business information, financial and HR information systems.

Every effort will be made to mitigate these risks through 2019. Our dedicated teams and staff will continue to work towards maximising all resources to ensure provision of high quality, safe and effective services to our population.

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Section 2 Clinical Quality Patient

Safety

Background

Quality Patient Safety is a key priority for South East Community Healthcare. Over the last

two years we have re-configured our Quality Patient Safety (QPS) team and appointed a QPS

Manager; 2 additional QPS advisors, administrative support and a Health and Safety Officer.

We have developed a Regional QPS team from which we have assigned QPS advisors to act

as a support to each of our care groups.

There has also been significant change at National QPS level resulting in the formation of

the single National Community Healthcare Quality and Patient Safety Office in 2018.

2018 saw the development and launch of the National Incident Management Framework

and the prioritisation of Open Disclosure following the publication of the Scally report

(2018) and the enactment of Part 4 of the Civil Liability Bill.

Throughout these changes and developments, the following core elements have been and

continue to be the foundation stone of Quality Patient Safety within South East Community

Healthcare:

Governance

Reporting

Learning

Compliance

During 2018, we worked with National Quality Improvement Division to review the

organisational structure and governance of QPS within South East Community Healthcare.

The report and recommendations from this review included an options appraisal to give

greater oversight and assurance to the Chief Officer. In 2019, we will be working to

implement these recommendations.

Priorities and Actions

In 2019, we will continue to build on the work which commenced in 2018 and the

requirements of Sláintecare, Compliance and the Patient Safety Strategy.

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The following areas are identified as priority:

The implementation of the Incident Management Framework within South East Community

Healthcare will be a target project with a project team commencing in January 2019. Open

Disclosure will be implemented in South East Community Healthcare in line with the

recommendations from the Scally Report 2018. A sub group of the project team will identify

a strategy for training in Open Disclosure for the year. It is hoped that After Action Reviews

will become a standard tool for South East Community Healthcare and the early

identification of persons to be trained in 2019 is paramount.

The assessment of primary care services against Safer Better Healthcare will be a continuous

process and will include the completion of patient surveys.

In order to improve the Quality of data and reporting of incidents onto the National Incident

Management System (NIMS), South East Community Healthcare will prioritise the time

delay between incident and reporting with a view to finding a workable solution to meet the

Key performance Indicator of all incidents being reported to NIMS within < 30 days.

The completion of review pages for all Grade 1 incidents will also be a targeted Key

Performance measure.

QPS will support the national development of the Patient Safety Strategy, in particularly in

the area of Falls, Pressure wounds and Infection Prevention Control.

Priority Priority Action Timeline Lead

Incident Management Framework

A Working Project Group will be formed which will oversee the roll out of and compliance with Incident Management Framework across the South East Community Healthcare

By the end of Q4 2019

Head of Health &Wellbeing/ QPS Manager

Open Disclosure Working group will be formed to oversee

the rollout of the revised open disclosure policy and identify training needs and develop the training plan for 2019/2020.

By the end of Q4 2019

QPS Manager/Open Disclosure Lead

Reporting NIMS To prioritise the time delay between

incident and reporting

The completion of review pages for all Grade 1 Incidents

Q1 – Q4

Q1 – Q4

QPS Manager

QPS Advisors

After Action Review (AAR)

After Action Review will become a standard tool for South East Community Healthcare. To achieve this a critical

Q4 2019

Heads of Service/QPS Manager

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mass of AAR facilitators to be in place across the entire geographical area

Safer Better Healthcare The continued assessment of Primary

Care services against the Safer Better Healthcare.

Continued involvement and active participation in the National Safer Better Healthcare Forums.

Patient Surveys feedback

Q1 – Q4

Q1 – Q4

Q1

QPS Advisor Primary Care

Development of QPS Structures

To fill the vacant QPS advisor post

Implement the QPS model developments as agreed by the Chief Officer.

Identify training and knowledge needs through the use of the Knowledge and skills guide.

Q1 2019 QPS Manager

Head of Health and Wellbeing

QPS Manager

Falls Group The continued development of A Falls

Group across the South East Community Healthcare to discuss incidents and learning from those incidents

Q1 – Q4

QPS Advisor Social Care

Safer Medicines Programme

Extension of the HSE medication safety work into our residential, home care and out-patient settings.

Q1 – Q4

All heads of staff

Healthcare Associated Infections (HCAI)

Examine our HCAI structures and resources to ensure prioritisation of infection prevention control across all service areas

Q4


Management and Reduction of Violence, Harassment and Aggression within the workplace

Release of staff for the appropriate level of training in Management and Reduction of violence, harassment and aggression within the workplace.

Prioritisation of services based on risk

Q1 – Q4

Q1 – Q4

All Heads of Service

Pressure Ulcers Implementation of the recommendations

from the Review of Pressure Ulcers in Mental Health Services

Sharing of the learning from this review across the South East Community Healthcare

Q1 – Q4


QPS Manager

Policies Agree and establish a cross divisional

document control system for all regional policies

Q3

Head of Service/QPS Manager

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Health and Safety

South East Community Healthcare is committed to putting in place a Health and Safety

Management System that is compliant with the Safety, Health and Welfare at Work Act

2005 and associated legislations. The Management of Occupational Safety, Health and

Wellbeing are vital to the continuous development of our service by protecting the most

valuable asset of South East Community Healthcare, our employees.

Health and Safety key delivery priorities for 2019 are:

Support and advise local management on establishing a robust system of Health and

Safety Governance in South East Community Healthcare.

Provide advice and assistance to managers and employees on health and safety related

issues and improve their Health and Safety Knowledge.

Working in partnership with HSE National Health and Safety Function (NHSF) and the

States Claims Agency to allow better use of resources.

Work with local Health and Safety Governance Committees to provide advice and

assistance with Health and Safety issues that arise.

Promote the NHSF safety Web-pages and promotional campaigns.

Collect and analyse National Key Performance Indicators (KPI’s) on a quarterly basis for


Communicate all Health and Safety Policies and assist with implementation locally.

Drive and promote local awareness of mandatory training. Communicate the need for

training and promote supports available both locally and nationally.

Assist locally with the preparation for the Level 1 Audit tool.

Our 2019 priorities are included below and will be delivered through planned general

inspections, investigation of NIMS forms; advice and visits to premises, follow-up revisits to

check implementations and improvements, attending local governance meetings, and

presentations.

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Health and Safety Statement

Finalise South East Community Healthcare’s Health and Safety Statement.

Q2

Health & Safety Officer

Health and Safety Audits Pilot of two sites with NHSF

Support disciplines and the NHSF in

preparing for and the carrying out of

Health and Safety Level 1 Audits across

the South East Community Healthcare

Q4 2018

Q2 – Q4

NHSF/ H&Safety Officer

Health & Safety Officer

Dangerous Goods Safety Advisor (DGSA)

Activate the DGSA contract across South East Community Healthcare

Complete approximately 13 onsite Dangerous Goods Audits

Complete the DGSA Annual Report

Q2

Q2 – Q4

Q4

H&S Officer

H&S Officer

DGSA

Work Positive Tool Launch the Work Positive Tool pilot in

South East Community Healthcare

Support the implementation of the Work Positive Tool Pilot

Q1

Q1 – Q4


Health and Safety Officer

Performance Indicators Collate the National Occupational Health

and Safety KPIs for South East Community Healthcare on a quarterly basis.

Support care groups to examine incident trends and agree a targeted intervention plan

Work with colleagues nationally to create a metadata to help managers when completing the National Occupational Health and Safety KPIs. Create guidance and support to encourage good returns.

Q2 – Q4

Q3


H&S Officer

H&S Officer

Presentations/Training Complete occupational health and safety

awareness presentation to management and staff in South East Community Healthcare

Q2 – Q4

H&S Officer

Patient and Service User Engagement Partnering with patients, service users and families to learn from their experience is an

essential component in enabling improvements in care and ensuring a quality, effective and

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safe service that is responsive to the needs of patients and service users. They will need to

be central to the design, planning and commissioning of services.

During 2019, South East Community Healthcare will continue to develop Your Voice Matters

(Patient Narrative Project) to enable patient experiences to be captured innovatively by the

HSE and to support the implementation of local service improvement initiatives.

This work to date has included stakeholder engagement and collection of patient

experiences (466 to date). This will be collated and used to promote service improvement

activities, build local capacity, and develop processes for engagement with and use of

service user experience and narratives.

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Section 3 Health & Wellbeing

Population

A fundamental goal of our health service is to support the health and wellbeing of our

population within the South East. Sláintecare recognises the importance of supporting

people to look after and protect their own health and wellbeing. Healthy Ireland is the

national strategy for improved health and wellbeing. It was developed in response to a

number of significant public health challenges, including significant projected increases in

levels of preventable chronic disease and growing heath inequalities. It articulates four

central goals for improved health and wellbeing:

Increasing the proportion of Irish people who are healthy at all stages of life

Reducing health inequalities

Protecting the public from threats to health and wellbeing

Creating an environment where every sector of society can play its part.

Healthy Ireland within the health services identifies three priority areas for the HSE:

Health Service Reform – our greatest opportunity

Reducing the burden of Chronic Disease – our greatest challenge

Improving staff health and wellbeing – our greatest asset

Healthy Ireland asserts that population health and wellbeing is critical for our social,

economic and cultural progress, and our overall quality of life. It recognises the requirement

for a ‘whole of Government’ approach to addressing the social determinants and predictors

of health and wellbeing, many of which fall outside the health sector, e.g. housing,

transportation, education, workplaces and environment along with an individual’s

socio‑economic status.

We know that giving the same service to everyone does not mean that everyone will have

the same positive health outcomes. We need to ensure that our services are matched to

each individual’s own health needs and that our health assessments take account of all

factors that can impact on health.

Healthy Ireland also provides for an inclusive, partnership approach to improve population

health and wellbeing by shifting our emphasis to prevention, and to empowering individuals

and communities by supporting them to take more responsibility for their health and

wellbeing.

21

There are many positive trends visible within our health service: life expectancy is

increasing; mortality rates are declining; and survival rates from conditions such as heart

disease, stroke and cancer are improving. Despite these encouraging developments, we

know changing lifestyles, chronic disease patterns and ageing population trends are altering

our population’s healthcare needs. To address these challenges we will continue to

prioritise high quality evidence based prevention, early intervention and health protection

strategies to help reduce demand on our health and social care services thereby ensuring a

sustainable health system for future generations.

Our Health and Wellbeing Services are dedicated to improving health across the region with

a commitment to:

Implement year one of our South East Community Healthcare Healthy Ireland

Implementation plan 2019-2022

Support implementation of Making Every Contact Count (MECC) across the region

and in particular within identified learning sites

Work with Local Community Development Committee’s (LCDC’s) and Children and

Young People’s Services (CYPSC) to implement county based Healthy Ireland plans,

to reduce smoking prevalence of young people in out-of-school settings and to work

towards making health everyone’s business

Work with the community and voluntary sector to increase healthy eating and active

living

Development of a Self-Management Support Regional Action Plan

Increase uptake of flu vaccination

Pilot social prescribing model in Waterford

Enhance the health and wellbeing of staff within the health services

Provide leadership in regional emergency planning functions

Develop and implement a work programme for the prevention and control of

Healthcare Associated Infections (HCAI’s)

Services Provided

Population health is about supporting all those who reside in the South East to stay healthy

and well by focusing on prevention, protection, and health promotion and improvement

including the following:

Local implementation of the National Policy Priority Programmes for tobacco,

alcohol, healthy eating, active living, sexual health and crisis pregnancy and child

health expertise, strategic advice and direction to address known preventable

22

lifestyle risk factors by designing and developing evidence based best practice

policies, programmes and initiatives.

Health Promotion and Improvement which provides a range of education and

training programmes focused primarily on building the capacity of staff across the

health service and in key external bodies who are ideally placed to positively

influence health behaviour. Health and wellbeing services work with people across a

variety of settings in the community, in hospitals, in schools and in workplaces.

Public health services which protect our population from threats to their health and

wellbeing through the design and oversight of national immunisation and

vaccination programmes and actions for the prevention and control of infectious

diseases.

National screening services which provide population-based screening programmes

for BreastCheck, CervicalCheck, BowelScreen and Diabetic RetinaScreen.

Issues and Opportunities

Our demographic profile is changing and is placing substantial pressure on our health and

social care services. Demand for healthcare services will increase by between 20% and 30%

in the next ten years. Unhealthy lifestyle choices such as those related to diet, exercise,

smoking and alcohol use are all driving demand for health services and resulting in an

increased level of chronic disease amongst our population.

Building upon Sláintecare and HSE structural reforms and enablers create greater capacity

within the organisation to lead and deliver upon the health and wellbeing reform agenda.

The development and implementation of comprehensive Healthy Ireland plans in CHO’s and

Hospital Groups will deliver upon the health and wellbeing reform agenda locally, improving

the health and wellbeing of the South East population by reducing the burden of chronic

disease and also improving staff health and wellbeing. The transition of Health Promotion

and Improvement to CHO’s will significantly augment existing health and wellbeing

resources supporting accelerated embedding and integration of health and wellbeing across

services locally.

A detailed national framework has been developed which outlines how to progress

implementation of Self-Management Support for chronic diseases. Through the

implementation of the Making Every Contact Count (MECC) Programme, and the Self-

Management Support Framework, chronic disease prevention and management will be an

integral and routine part of clinical care by all healthcare professionals enabling them to

capitalise on the opportunities that occur every day to support individuals to make healthier

lifestyle choices.

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Priorities 2019

Improve the health and wellbeing of the population by reducing the burden of

chronic disease.

Build upon Sláintecare and HSE structural reforms and enablers to create greater

capacity within the organisation to lead and deliver upon the health and wellbeing

reform agenda.

Early Years Intervention including the National Healthy Childhood and Nurture Infant

Health and Wellbeing Programmes.

Protect our population from threats to health and wellbeing through infectious

disease control, immunisation, and environmental health services.

Improve staff health and wellbeing.

Implementing Priorities in 2019


South East Community Healthcare’s Healthy Ireland Plan

Launch South East Community Healthcare’s Healthy Ireland (HI) plan.

Commence year 1 of the implementation of South East Community Healthcare HI Plan to deliver actions and embed prevention, early detection and self-management support among their staff and the communities they serve

Jan 2019

Q1- Q4

HoHWB

HoHWB

Chronic disease prevention & Self-management support

(SMS)

Establish local governance structure for Self- Management Support

Q1

HWB

Primary Care

Self-Management Support

Continue the implementation of Living Well with a Chronic Condition: Framework for Self-Management Support and support for the integrated chronic disease programme.

Q1- Q4

Self-Management Support Co-ordinator


Increase the provision of access to Chronic Disease SMS Programme

Q1- Q4


24

(CDSMP) within the South East


Finalise the mapping for Self- Management Support within the South East & the development of a directory of services/supports

Q1



Develop a South East Plan for Self-Management Support

Q2



Ensure Self-Management Support materials are kept up to date and are displayed in public facing areas

Ongoing



Support the development of a patient guide to Self-Management Support

Q3



Work to support the increase in provision and access to Self-Management supports such as: Pulmonary Rehabilitation and Cardio Rehabilitation

Q4



Develop the Peer Support Groups in each county within the South East

Q1-Q4


Structured Patient Education

Work with dietetic services to improve access and uptake of structured patient education programmes for patients with Type 2 Diabetes in the community

Q1-Q4

Self-Management Support Co-ordinator HoHWB

Primary Care

MECC Implementation of Making Every

Contact Count across the following learning sites: Carrick-on-Suir Health Centre; Regional Podiatry Service; Wexford Traveller Health Project; Residential Learning Disability Services in South Tipperary & the Dept of Psychiatry in Waterford

Q1 – Q4

Heads of Services/

HoHWB/

HP&I

MECC Evaluate the MECC learning sites

Q4 HoHWB

Alcohol Promote and support the

askaboutalcohol campaign to increase awareness of the risks associated with alcohol intake.

Ongoing

HoHWB

Alcohol Support Alcohol and Substance

misuse policy development with all secondary and third level colleges

Ongoing

Primary Care Social Inclusion

Alcohol Challenge social norms and myths

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relating to alcohol harm by providing evidence based information on health impacts and social & psychological impacts on families and Children

Q4 HoHWB

Alcohol Provide tailored prevention and

early intervention programmes via drug education officers and community based drug initiative workers

Ongoing

Primary Care

Social Inclusion

Healthy Childhood

Support the implementation of the Framework for the National Healthy Childhood Programme, including the Nurture – Infant Health & Wellbeing Programme

Ongoing Heads of Service

Child health lead primary care

Healthy Childhood

Map the availability of parenting courses in South East Community Healthcare and provide an overview of parenting courses available in South East Community Healthcare

Q2

HoWB

Healthy Childhood

Support South East Community Healthcare initiatives such as Lift the Lip; Snuggles Stories; books for babies

Ongoing

HWB

Healthy Childhood

Where possible, facilitate staff to complete the relevant training in child health modules such as

- Children First Training

- Breastfeeding training

- Nutrition blended e-learning training (as part of nurture programme)

- Multi-level training to promote Infant Mental Health (as part of the Nurture Programme)

- Substance Misuse & Pregnancy training programme being co-developed with NMPDU/RCNME and Substance Misuse

Q4

Heads of Service

Healthy Childhood

Support the implementation of the HSE Breastfeeding Implementation Plan

Q4 Primary Care HWB

Healthy Childhood

Support the roll out child mental health pathway poster in partnership with CYPSC.

Q4 In Partnership with CYPSC

Healthy Childhood

Support Schools to develop health and wellbeing plans and provide health and wellbeing training to

Q1 – Q4

HP & I

26

teachers on a range of nationally agreed topics

Tobacco Free Continue to Implement the Regional

Tobacco Free Positive Messaging Initiatives across the South East Community Healthcare and in partnership with youth organisations and the 5 LCDC’s across the South East Region.

Q1- Q4

HWB with LCDC’s

Tobacco Free Support staff to quit and stay quit

and continue to provide subsidised Nicotine Replacement Therapy for HSE staff who wish to QUIT

Ongoing

HWB

Tobacco Free Ensure that QUIT support resources

will be displayed in all appropriate South East Community Healthcare sites


Tobacco Free Support National communication

campaigns

Ongoing

HWB

Tobacco Free Support the delivery of smoking

cessation interventions particularly targeting high risk groups

Ongoing

HWB

Tobacco Free Support the implementation and

monitoring of Tobacco Free Campus Policy across all sites and services

Ongoing

All HOS

Healthy Eating Active Living

Support the delivery of Community Nutrition and Cookery Programmes across the South East Community Healthcare in partnership with the community and voluntary organisations and LCDC’s and CYPSC

Q1- Q4

HWB

HP&I


Link with county GAA Health and Wellbeing Committees to support the rollout of the Healthy Club Programme

Q3

HWB

HP&I


Support Implementation of HSE Vending policy across the Health Services

Q1- Q4

Heads of Service


Support the implementation of Healthy Weight for Children Prevention Programme

Q4

HWB

Primary Care HP&I

Healthy Eating Continue to support the delivery of

Ongoing HOS

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Active Living the START Campaign


Work in collaboration with Local Sports Partnerships to increase public participation in physical activity

Q1- Q4

HWB

HP&I

Mental Health and Wellbeing

Continue to support the roll out of the “Little things campaign”

Ongoing HWB All HOS


Pilot in South East Community Healthcare ‘Minding your Well Being’ – pilot study being carried out nationally & evaluation by IT Carlow

Q4

HP&I


Roll out Introduction to Youth Mental Health & Minding Youth Mental Health

Q4 HP&I


Support social prescribing project in Waterford

Ongoing HWB HP&I


Continue to support interagency mental wellbeing groups/committees to deliver specific wellbeing initiatives such as the “Music in Mind refugee Programme” “Mind your Mental Health” ‘Traveller Wellbeing Check-In Tool’ and ‘It’s your Choice ’Programme

Ongoing

Social Inclusion

Positive Aging Support the delivery of Age with

Confidence, Taking Stock

Q4 HP&I

Positive Aging Support the work of Age Friendly

Programmes in each of the counties within the South East

Q4

HWB HP&I

Positive Aging Support the Understand Dementia

Campaign within the South East

Q4 All HOS HP&I

Positive Aging Review regional guidelines for the

management of malnutrition in line with the new national guidelines once developed.

When developed Community Dieticians

Positive Aging Continue the South East QPS Falls

Cross Care Group Initiative

Ongoing All Heads of Service

Regional Flu Promote and increase the uptake of

the Flu Vaccine amongst residents in our Long-term Care facilities and HSE staff

Flu Season All HOS

Positive Sexual Health

Disseminate the Good Practice poster from the South East Positive Sexual Health Seminar held in Nov 2018

Q2 HWB


Support implementation of evidenced informed sexual health

On-going HWB

HP&I Social

28

training programmes

Inclusion


Work in partnership with HSE colleagues, statutory and voluntary bodies to support local/regional sexual health

On-going HWB

HP&I

Social Inclusion


Implement process to ensure that all staff are aware of the available free sexual health resources and training opportunities (Condom distribution service, Health promotion material, HSE & HSE funded training) and encourage uptake

Q4 HWB

HP&I

Social Inclusion

Partnership Working

Continue to work in partnership with the 5 LCDC’s and 5 CYPSC in the South East

Ongoing HoHW

HP&I

Emergency Planning

Finalise the South East Community Healthcare emergency plan

Q1 HoHWB

Continue to support Local

Authorities in the development of community resilience across the South East

Ongoing HoHWB

Participate in the feasibility study to

develop resilience desks in the South East

Q1 HoHWB

Immunisation Continue to promote and support

the uptake of childhood vaccinations within the South East

Ongoing HoHWB

Primary Care

Screening Programmes

Continue to identify and work with the National Cancer Control Programme to target the promotion of the uptake of screening services in areas which are low within the South East

Ongoing HoHWB

Primary care

Staff health and Wellbeing

Continue to support the enhancement of Staff health and wellbeing through the development of Healthy Ireland in the workplace group

Ongoing HWB


Continue to support staff health and wellbeing initiatives including mindfulness and yoga within the workplace

Ongoing HWB


Continue to support COOK It for staff across the South East

Ongoing HWB


Support the Reclaim Your Lunch Campaign for staff


Staff health and Support the provision of ‘Resilience

Q4 HP&I/HR

29

Wellbeing in the Workplace’ workshops


Support the piloting of Work Positive Tool in South East Community Healthcare

Q1- Q4 HoHWB HR, all HOS


Continue to support healthy eating and active living for staff such as Steps to Health and Love Life Love Walking

Ongoing HoHWB

Staff health & Wellbeing

Continue to progress a culture of person centeredness in South East Community Healthcare

Ongoing HWB

Staff health & Wellbeing

Continue to roll out the Smarter Travel pilot initiative in Kilkenny

Ongoing HWB

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Section 4 Primary Care Services

Services Provided

In 2019, Primary Care will provide clear leadership and deliver on our statutory commitments and work to progress and implement, as appropriate, the key priorities and actions as set out in the National Service Plan for 2019. The core objective of Primary Care services in the South East is to achieve a more balanced

health service by ensuring that the vast majority of service users and service users who

require urgent or planned care are managed within Primary and community based settings,

while ensuring that services are:

Safe and of the highest quality;

Responsive and accessible to service users’ needs;

Highly efficient and represent good value for money;

Well integrated and aligned with the relevant specialist services.

Primary Care services include Primary Care teams (PCTs), community network services,

community schemes and social inclusion. Reference to Primary Care throughout this plan

includes reference to all of these services. The Primary Care Team is the starting point for

service delivery, consisting of general practice, community nursing, physiotherapy,

occupational therapy and speech and language therapy, serving a population of

approximately 7,000 to 10,000 people. Community network services include audiology,

ophthalmology, dietetics, podiatry, psychology and oral health services. Other Primary Care

services include GP out of hours, diagnostic services and community intervention teams

(CITs) and children supported at home by way of paediatric home care packages.

Enhanced Primary Care is a key element of the overall Health Reform programme to ensure

a sustainable health service. In 2019, South East Community Healthcare will continue to

enhance core Primary Care services and develop innovative initiatives to respond to the

presenting needs of its population. We will respond to key initiatives planned under

Sláintecare to further develop services in the region with the overall aim of improving health

outcomes of the population in the South East. Acknowledging the direct impact that poverty

and social exclusion have on the health and wellbeing of our population, a key aspect of

service development will be the focused provision of social inclusion services to improve

health outcomes for those who are most vulnerable in our community. The Role of Social

Inclusion Services is:

To improve access to mainstream and targeted health services for people from

disadvantaged groups;

31

To reduce inequalities in health;

We also aim to enhance the participation of socially excluded groups and

communities in health services.


Demographic changes including an increased birth rate and ageing population are leading to

greater numbers of patients presenting to Primary Care services in the South East and a

change in the profile of care needs in our population. In particular, there is a notable

increase in demand for services for age related chronic conditions. The demand for GP

services, community nursing services and therapy services is at an all-time high. The

changing socio-demographic profile in the South East in recent years has also led to

increasing demand for Social Inclusion services; particularly substance misuse services,

homelessness services and services to refugees, which are often beyond funded levels.

Infrastructural challenges

It is internationally recognised that the strategic repositioning of Primary Care at the core of

health service provision is critical to meet the escalating demand on health services and

ensure appropriate care provision for the changing profile of care needs presenting as a

result of population ageing and its associated increase in chronic condition prevalence.

Accessible, comprehensive, continuous, and co-ordinated Primary Care is central to better

serving the needs of our population.

Deficits in ICT, in particular digital information systems, continue to pose a significant

challenge to coordinated, integrated Primary Care service delivery in the South East. The

absence of ICT solutions to service user management and related clinical time lost will

continue to impact on service efficiency in 2019.

Resource Constraints

While striving to provide the highest quality of Primary Care service provision, a key

challenge for 2019 will be the capacity to maintain existing levels of service in a number of

key areas against the backdrop of increasing demand and system and resource constraints.

Overall reductions in funded levels of primary care activity inevitably have implications on

provision of community demand-led schemes, although this can be partially mitigated on

the assumption that certain developments will have implementation time delays.

The ongoing control of pay and staff numbers will impact on performance in 2019. In

particular, accessing waiting times for occupational therapy, ophthalmology, audiology,

dietetics, podiatry, psychology will present challenges.

Maintaining complex paediatric home Care packages to funded levels in the context of

increasing demand and earlier discharge from acute services will be a particular challenge.

32

Enhanced Care Opportunities

Development of Primary Care Centres continues to enhance the operation of PCTs and

network services in the South East and the planned role out of an agreed, modernised

contract for the provision of General Practice services will enable a more structured

approach to chronic condition management with potential to improve care outcomes for a

significant proportion of our population. GP access to diagnostic (ultrasound) services

remains a key capacity deficit in supporting the decisive healthcare policy shift to Primary

Care. The phased roll out of community diagnostics has commenced in certain geographic

areas of greatest need in the South East with further roll out planned, increasing potential

for efficiencies in Primary Care in 2019.

Priorities 2019

Improve quality, safety, access and responsiveness of Primary Care services and

implement learning sites in South East Community Healthcare in line with

SláinteCare.

Improve access for Primary Care Therapy services with a focus on addressing patients

waiting over 52 weeks.

Improving GP access to diagnostics will be aided by the provision of community

diagnostic provision in Primary Care locations in 2019.

Continue to build on success of Community Intervention Teams (CITs) by providing

treatment for in excess of 6,468 referrals across Carlow/Kilkenny, South Tipperary and

Waterford. Strengthen the focus on hospital admission avoidance and early discharge

from acute hospital settings.

Deliver Healthy Ireland actions as appropriate to Primary Care.

Further develop effective care pathways between acute and Primary Care services

with a focus on integrating care for chronic conditions.

Progress the implementation of the national Healthy Childhood and Nurture

programmes and provide packages of care for children discharged from hospital with

complex medical conditions to funded levels.

Improve access to mainstream and targeted health services for people from

disadvantaged groups and reduce inequalities in health and enhance the

participation of socially excluded groups and communities in health services.

Termination of Pregnancy - Develop termination of pregnancy services in line with

the vision of SláinteCare to ensure access in community settings through Primary

Care providers.

33

Antimicrobial Resistance and Infection Prevention and Control - Improve the

management of antimicrobial resistance and infection prevention and control in our

services within our community.

Ensure treatment is offered to patients with hepatitis C in line with the National

Hepatitis C Treatment Programme goal of eliminating hepatitis C by 2026.

The development and implementation of a Primary Care Patient Management System

to facilitate referrals between primary care teams and networks, and specialist and

acute care, improve communication and support integrated patient care is a key

priority.



Community Intervention Teams (CITs)

Continue to build on the success of the Community Intervention Teams (CIT’s) in South East Community Healthcare

Strengthen the focus on admission avoidance and early supported discharge through the CIT Governance Group

Develop appropriate care pathways accounting for clinical need in the local care context

Treating over 6,500 referrals across the CHO in 2019

Support hospitals in increasing the proportion of service users who are taught to self-administer compounded IV antibiotics SOPAT

Ongoing

Q3

Q4

Primary Care Development Officers

Community Diagnostics Deliver GP access to Community Diagnostics

Expand GP access to ultrasound in Our Lady’s Health Campus, Cashel and to x-ray in Carlow/Kilkenny and Cashel

Strengthen the referral pathway to the new GP access to ultrasound facility in Carlow

Ongoing Primary Care Development Officers

Physiotherapy Deliver high quality Physiotherapy Services, responsive to clinical need of the population.

Deliver evidence based physiotherapy programmes across South East Community Healthcare including:

- 8 Chronic Low Back Pain group education sessions in Carlow/Kilkenny.

- a 6 week Multiple Sclerosis fatigue management education programme in South Tipperary

Ongoing

Q1- Q4

Physiotherapy Managers

34

and 2 ‘Getting the Balance Right’ groups in Cashel

- 6 Parkinson’s Disease Aerobic and Balance Training sessions in Cashel

- 6 Stroke Aerobic and Balance training Sessions in Cashel

- bone health education programmes in Wexford

- roll out back care programme in Wexford Town Sector

- roll out knee and shoulder group rehab session to CHN locations in New Ross, Enniscorthy and Gorey

Continued development of Knee Class with University Hospital Waterford.

Review and update the balance and falls programme in Carlow/Kilkenny in collaboration with St. Luke’s Hospital and Older Person’s services

Implement Frailty Assessment in 6 Primary Care Teams in Carlow and South Kilkenny

Implement the Integrated Care Programme for Older People (ICPOP) in South Tipperary and commence and review physiotherapy direct referral to the Waterford Integrated Programme for Older People (WICOP) “falls and blackout” clinic.

Audit compliance of South East Community Healthcare Primary Care musculoskeletal assessment

Review feasibility of extending physiotherapy led orthotic clinics to paediatric clients with non complex needs in Wexford and commence process of improved management of paediatric service users transitioning to adult primary care service in relation to ongoing orthotic needs and monitoring in Waterford

Q2- Q3

Q3

Q2 – Q4

Q1 – Q2

Q2

Q2

Primary Care Psychology Deliver high quality Psychology services, responsive to identified clinical need of the population.

Optimise the contribution to service delivery of Assistant Psychologists through continuing to facilitate the agreed education and training programme across

Ongoing

Psychology Managers

35


Implement the Stepped Care Model in Carlow/Kilkenny and South Tipperary and pilot clinics with Assistant Psychologists for children on the waiting list with non-complex needs in South Tipperary/Wexford and Waterford in line with the Stepped Care Model

Develop assessment and intervention pathways in South Tipperary and develop consultation, assessment and intervention pathways in Carlow/Kilkenny

Roll out workshops and group based services to meet the needs of children and families on the waiting list in Carlow, Kilkenny, Wexford and Waterford

In collaboration with Social Care deliver 2 behaviour management group workshops for parents in South Tipperary

Implement and evaluate the Solihull Approach Parenting Programme in Carlow/Kilkenny

Roll out a community-based bibliotherapy initiative, in collaboration with local libraries in Carlow/Kilkenny

Support promotion of ‘Psychological Well-Being in Adolescence’ by delivering an Exam Stress workshop in secondary schools in Carlow/Kilkenny

Establish consultation with service users regarding service development in Carlow/Kilkenny and implement on-going evaluation of the service in Carlow/Kilkenny

Facilitate training placements for psychologists on recognised university programmes Wexford/Waterford

Roll-out individual supervision of psychologists as a quality initiative in Wexford/Waterford

Development of a suite of policies, procedures, protocols & guidelines (PPPG) for Psychology Department Wexford/Waterford

36

Speech and Language Deliver high quality Speech and Language Therapy services in line with the National Model

Implement the National Primary Care Speech and Language Therapy Model of Care in South East Community Healthcare

Deliver SLT Programmes across South East Community Healthcare:

o New Concept Development (vocabulary) groups for young children

o Hanen ‘Talkability’ Parent Training Programmes, in South Tipperary, Waterford and Wexford.

o ‘Tipp Tiny Talkers’ Parent Advice Sessions

o Development Language Disorder awareness training with teachers in South Tipperary

- Lamh/Baby Lamh in Wexford and Waterford

- Run dysphagia information sessions for families, nursing and care staff in Wexford and Waterford

In collaboration with South Tipperary General Hospital and Social Care, implement new Dysphagia Standard Induction Protocol for new staff

Implement Parent Advice Pathways in Carlow/Kilkenny as piloted in 2018

Develop and trial a paediatric speech fluency pathway and a speech sound pathway in Carlow/Kilkenny

Develop a FEDS pilot program with Occupational Therapy and dietetics to be held on a quarterly basis to address the needs of Primary Care Service Users and review content of FEDS awareness training sessions for nursing and care staff in line with satisfaction survey results in Carlow/Kilkenny

Progress parent training and coaching programs for: - children (0-6 years) with language

delay referred through the Primary Care Service in Waterford and

Ongoing

Q2- Q4

Q1- Q4

Q1- Q4

Q1- Q4

Q3- Q4

Q1

Q4

SLT Managers

37

Wexford - children (5-18 years) with social

communication delay and/or disorder referred through the Primary Care Service Waterford and Wexford

Deliver SLT training sessions for PHNs, library information sessions and targeted teacher training in Waterford and Wexford

Deliver evidence based pilot intervention groups for children with suspected Developmental Language Disorder (DLD)

Implement Narrative Skills group for older children with language disorder (1 x 5 week programme)

Implement Group Therapy Plan in Primary Care for children with a variety of speech deficits

Develop information programmes for families with acquired and progressive communication disorders and information sessions for clients and their families with acquired and progressive swallowing difficulties (dysphagia)

Re-Launch of Aphasia Café in Waterford

Q1 – Q4

Q4

Q4

Q4

Q3- Q4

Q4

Occupational Therapy Deliver high quality Occupational Therapy Services, responsive to identified population need.

Roll out adult outpatient clinics in all networks and provide dedicated ‘long waiters’ clinics to address the needs of the population in more timely manner and sustain reduction in waiting lists

Expand the fatigue management group programme for clients with cardiac and neurological conditions (Multiple Sclerosis, Motor Neuron Disease and arthritic conditions)

Implement Frailty Assessment in Primary Care Teams for over 75’s in Carlow/Kilkenny and support the integrated pathway for Frailty in collaboration with Wexford General Hospital

Support the Integrated Care Programme for Older Persons (ICPOP) by providing a timely service to enable Older Persons to

Ongoing

Q1 – Q4

Q1 – Q4

Q1 – Q4

Q1 – Q4

Occupational Therapist Managers

38

live well in Carlow/Kilkenny and South Tipperary and the roll out of two Well Elderly Groups in Waterford

Review of service audits and ongoing follow up on agreed actions by OT staff Wexford

Q1- Q4

Oral Health Deliver high quality Oral Health Services, responsive to identified population need

Support the implementation of targeted screening for areas that do not have access for 11-13 year olds to ensure national equity within available resources

Provide treatment for 11-13 year old children in prioritising public dental health i.e. fissure sealants within available resources

Support the implementation of the Clinical Governance Framework for oral health services, within a timeframe agreed for completion of infection control standards

National Dental Computerised Patient Recording System SOEL Health – Implementation and continued training of staff in South East Community Healthcare

Continuation of Lift the Lip programme in partnership with Public Health Nurses in Waterford and Wexford

Shared Learning – The ongoing and expanding programme of clinical audit will continue through 2019.

Ongoing Q2 Q1– Q3 Q1- Q4 Q1- Q4 Q1- Q4 Q1- Q4

Principal Dental Surgeons

Orthodontic Department Deliver high quality Orthodontic Department Services that respond to identified population need.

Reduce waiting times for orthodontic assessment with equity across South East Community Healthcare

Reduce the proportion of grade 4 and 5 service users on the treatment waiting list

Ongoing

Q4

Q4

Consultant Orthodontist

Ophthalmology Deliver high quality Ophthalmology Services that respond to identified need

Further roll out of the recommendations of the Primary Care Eye Services Review Group in Wexford

Training of staff in use of recently acquired Occular Computer Tomography (OCT) machine for treatment of patients

Ongoing

Q4

Q2

Ophthalmic Manager

39

with age related macular degeneration vascular pathology

Establishment of satellite eye clinic with University Hospital Waterford

Continuation of Eye Nurse training module for PHNs

Continue eye health promotion by Wexford Ophthalmologist and including a focus on smoking cessation with adult patients

Q2

Q3

Q3

Chronic Disease Deliver high quality chronic condition care in South East Community Healthcare by implementing nationally agreed Models of Care, responding to the identified need of the population.

Participate as an initial site for rollout of Making Every Contact Count, working in collaboration with Health and Wellbeing to support actions in relation to tobacco, alcohol, healthy eating, active living and positive ageing and wellbeing

Support the implementation of the Diabetes National Clinical Programme by:

- Delivering 20 dietetic-led structured patient education (SPE) programmes across the CHO

- Continue to expand the number of GP practices participating in the Diabetes Integrated Care Programme in Carlow/Kilkenny to 16 and 17 practices in South Tipperary

- Delivering diabetes education to health care professionals within South Tipperary

- Collaborate with St. Luke’s Hospital Kilkenny to continue to develop integrated care pathways

- Follow the delivery of the Model of Care for the Diabetic Foot according to the revised document due to be launched in 2019

- Continue to develop podiatry support to the travelling community and manage foot health problems relating to chronic conditions such as Diabetes as part of the multidisciplinary team

- Further development of Primary Care

Ongoing

Q1 – Q4

Q1 – Q4

Primary Care Development Officers and Integrated Care Clinicians

40

Paediatric Diabetic Clinics

- Develop, support and work collaboratively with GP practices, Public Health Nursing, UHW and other health professionals by providing education on foot health needs of service users with Diabetes and those with active foot disease as required in Waterford

- Provide education to health professions in relation to diabetes/chronic diseases and the impact on foot health and further develop relationships with health professionals working directly with those with additional issues, the homeless, refugees, asylum seeker and travellers and Roma communities to improve foot health related outcomes for those most vulnerable

Support the implementation of the National Clinical Programme for Heart Failure

- Recruit new GP practices in Carlow/Kilkenny area in accessing the Heart Failure Integrated Care Programme and utilising the Heart Failure Virtual Consultation/heart failure outreach clinic for specialist advice

- Establish a Heart Failure Peer Support group for Carlow/Kilkenny

- Continue data collection on Heart Failure population looking at prevalence and service gaps in diagnosis and treatments

- Create links to collaborate with Community Intervention Team (C.I.T) and community palliative care

- Enhance dietician services in Waterford/Wexford

Support the implementation of the National Respiratory Clinical Programme

- Plan the relocation of chronic disease management clinics from the acute setting to the new primary care centres

- Increase provision of respiratory education sessions across South

Q1 – Q4

Q1 – Q4

41

East Community Healthcare

- Expand provision of targeted pulmonary rehabilitation programmes

- Enhance respiratory physiotherapy service in Wexford

- Increase GP participation in the Respiratory Integrated care programme in Carlow/Kilkenny

- Initiate musculoskeletal (MSK) clinics in Waterford City Primary Care

Community Dietetics Deliver a high quality Dietetic Service, responding to identified population needs.

Implement recommendations from dietetic model of service delivery

Support completion of Scientific Recommendations for Healthy Eating Guidelines for Toddlers and Preschoolers

Healthy Eating & Active Living Programme:

Support the development of National Community Nutrition/Cooking Programme content and development of model of delivery in South East Community Healthcare

Deliver train the trainer sessions on new National Community Nutrition/Cooking Programme for teachers, health professionals and community workers

Support tutors trained to deliver programmes across South East Community Healthcare

In partnership with Waterford and Carlow Institutes of Technology, support Waterford Men’s Sheds to roll out Community Nutrition/Cooking Programme – deliver one training session to tutors and provide ongoing support to tutors in delivering programmes

Deliver eight group weight management programmes across PCTs in Clonmel, Tipperary Town, Waterford, Dungarvan, Enniscorthy, Gorey, Carlow and Kilkenny

Deliver dietetic assessment and therapy

Ongoing

Q1 – Q4

Q1 Q2- Q4 Q2 Q2- Q4 Q1- Q4

Dietician Manager

42

services in PCTs across South East Community Healthcare

Progress development of dietetic service in Waterford and South Tipperary in liaison with the Integrated Care Programme for Older People, to deliver pilot dietetics workshop as part of Occupational Therapy-led Well Elderly Clinic in Waterford

Deliver training to PCT members on community funded schemes service improvement – nutrition support in Clonmel, Tipperary Town, Waterford, Dungarvan, Enniscorthy, Gorey, Carlow and Kilkenny, for quality improvement

Q2- Q4

Q1- Q4

Occupational therapy manager and Dietician manager

Public Health Nursing Deliver high quality Public Health Nursing Service, responsive to identified population need.

Develop an integrated care team approach to discharge planning in collaboration with St. Luke’s Hospital Kilkenny (SLHK).

Deliver 17 nurse led Leg Ulcer Assessment and Wound Management clinics per week across South East Community Healthcare

Deliver 13 weekly Enuresis and Encopresis clinic and increase service provision for nocturnal enuresis; toilet training; constipation and soiling for all children in the Waterford area

Rollout of ASQ (Ages and Stages Questionnaire) for all 21-24 month developmental assessments as part of the National Healthy Childhood Programme in South East Community Healthcare

Rollout of National Healthy Childhood Programme – blended learning for all Public Health Nurses (PHN) in South East Community Healthcare

Rollout of Traveller Health Chronic Conditions Programme Pack, in response to the recommendations in the Traveller Health Unit South East Strategic Plan 2015-2020.

Lift the Lip initiative to continue in 2019 in partnership with Oral Health Waterford

Ongoing

Q1- Q4

Q1- Q4

Q1- Q4

Q1- Q4

Q1- Q4

Q1- Q4

Q4

Director of Nursing

43

and Wexford

Snuggle Stories to continue in 2019 in Waterford

Wexford PHN Department to deliver Books 4 Babies Universal Programme to all children who are receiving their 7-9 month developmental assessment.

Ongoing updating and management of the dementia project www.understandingtogether.ie. Work will commence with the Health & Wellbeing division to develop Bunclody as a Dementia Friendly Town.

Development of Older Persons Chart in South East Community Healthcare

Further develop integrated discharged planning with Wexford General incorporating Patient Flow and Discharge Planning

Provide face to face training to support seven online modules on infant nutrition/child health (blended learning), in Carlow/Kilkenny, South Tipperary, Waterford and Wexford

Q1-Q4

Q2-Q4

Q3

Q3

Q1- Q4

Q1- Q4

Nurture and Healthy Childhood Programmes

Develop implementation plan to progress the delivery of the Healthy Childhood and Nurture programmes in South East Community Healthcare:

Provision of Public Health Nursing Services that are responsive to local child health needs

Increase childhood immunisation and associated boosters and promote the update of HPV etc in older age children

Ensure that 98% of newborn babies are visited by a PHN within 72 hours of discharge from maternity services

Ensure 95% of children have had child development screening on time or before reaching 10 months of age

In line with the HSE Breastfeeding Action Plan 2016-2021 increase the percentage of babies breastfed at the first PHN visit and at 3 month PHN developmental check to meet KPI’s in South East

Ongoing

Q1 –Q4

Q1- Q4

Q1- Q4

Q1- Q4

Q1- Q2

DPHNs and HoS PC

http://www.understandingtogether.ie/

44

Community Healthcare

Development of weaning Clinics with initial input from Dieticians Waterford

Roll out of the BOAT Tool to all breastfeeding mothers in Wexford

Introduction of Lactation Consultant Clinics

Q1- Q4

Q1- Q4

Q1- Q4

Quality and Patient Safety

Improving the management of antimicrobial resistance and infection prevention and control in our services and within our community.

Ongoing

HoS PC

Primary Care

Progress the implementation of Services in Primary Care

Update the current Primary Care Team – Clinical Team Meeting (CTM) guidelines

Improvement of Information for Service Users in Primary Care

Develop Patient Information Leaflets for both new Primary Care Centres – Waterford City and Dungarvan illustrating the services provided on site in both centres

Provide information in both primary care centres on Your Service Your Say and the Complaints Procedure to members of the public in all awaiting areas

Cervical Screen Support – Liaison Officer for South East Community Healthcare will continue to provide support to the 221 + Group. Providing access for these patients in a timely manner on the following:

- Support will be provided under the packages of supports to assist both psychology and financially as required

- The Liaison Officer will continue to link in with the other cervical screening support offices via weekly teleconference and attend meetings as required until a formal process is put in place nationally

Deliver awareness raising sessions on

Ongoing

Q1 – Q3

Q1 – Q3

Q1 – Q4

Q2 – Q3

Q1 – Q4

Primary Care Lead

45

Elder Abuse to attendees at Day Care Centres in the Carrick on Suir, Slieveardagh and Cashel areas

Q1- Q4

Primary Care Social Work

In collaboration with Primary Care Psychology, continue to progress the Infant Mental Health Study Group in order to promote early intervention work with relevant client group

Ongoing

Primary Care Social Workers

Clinical Nurse Specialists Mental Health

Primary Care Clinical Nurse Specialists in Mental Health will provide early intervention, assessment and as appropriate psychotherapeutic interventions for service users between 16 and 65 yrs

Strengthen the relationship between Primary and Secondary Care through monthly Secondary Care Mental Health Service multi-disciplinary team meetings

Deliver a monthly (demand-led) Primary Care mental well-being information clinic in Clonmel

In collaboration with the senior medical social worker maternity services, South Tipperary General Hospital, develop and deliver 2 Mellow Bumps offers support to pregnant women with additional social care needs

Ongoing CNS MH Lead

46

Social Inclusion Services

Services Provided

HSE Social inclusion works across a range of statutory services in partnership with the

community and voluntary sectors, to improve access to health services for disadvantaged

groups. Improving health outcomes for the most vulnerable in society is the key focus of

Social Inclusion services. This includes provision of targeted interventions for people from

marginalised groups who experience health inequalities, have difficulties accessing services

and present with multiple, complex health and support needs. Various studies have

illustrated that homeless, Traveller and migrant populations face greater health care needs

than the general population. Primary Care has a major role to play in relation to the health

of people with addictions or those who are homeless, and in delivering on commitments

such as the Refugee Relocation Programme. Vulnerable people and communities include

Travellers and Roma, asylum seekers, refugees and lesbian, gay, bisexual, transgender and

intersex service users.


Ensuring that we improve service user outcomes for those most vulnerable in society is a

key priority. Capacity to meet government commitments as set out in the Refugee

Protection Programme / EU Relocation and Resettlement Programme, Rebuilding Ireland

Action Plan for Housing and Homelessness, 2016, Housing First National Implementation

Plan 2018-2021 and the National Drug Strategy: Reducing Harm, Supporting Recovery – A

health led response to drug and alcohol use in Ireland 2017-2025 will support more effective

social inclusion.


Improve health outcomes for the most vulnerable in society including those with

addiction issues, the homeless, refugees, asylum seekers and Traveller and Roma

communities.

Implement the health actions, identified as a priority in 2019, in Rebuilding Ireland

Action Plan for Housing and Homelessness, 2016 and Housing First National

Implementation Plan, 2018 - 2021, in order to provide the most appropriate Primary

Care and specialist addiction / mental health services for homeless people.

Improve access to Primary Care services for refugees in emergency reception and

orientation centres / resettlement phase, with a focus on chronic disease management,

increasing access to mental health supports and addressing the oral health needs of

children and adults.

Provide targeted interventions as a means of reducing health inequalities in the Traveller

and Roma communities, with a focus on improving mental health and reducing the rate

of suicide.

47

Implement agreed HSE assigned actions under the Second National Strategy on

Domestic, Sexual and Gender-based Violence 2016-2021 within existing resources.



Refugees, Asylum Seekers & Roma

Further development of South East Regional Intercultural Health structures for both funded agencies and the Intercultural Peer Health Workers network.

Support the development of annual health work plans for target groups that are aligned to relevant health policies, frameworks and standards as well as the new National Intercultural Health Strategy and the Strategic Plans for Intercultural Health in the South East

Through the Regional structures provide interactive workshops on relevant health policies, strategies, frameworks and standards and their relevance to planning health work and measuring health outcomes.

Develop the South East Community Healthcare Intercultural Heath Training as an online tool for staff in partnership with national Social Inclusion Office.

Launch South East Community Healthcare Vulnerable Migrant Health Research.

Further develop the Primary Healthcare In-reach Project in Clonea EROC. Support dental and Mental Health Services to develop service and supports aligned to the Project Model.

Promote the health and wellbeing of the Roma Population through the Roma Health Advocacy Projects in Wexford and Waterford and their work in implementing relevant actions in the National Traveller and Roma Inclusion Strategy (2017-2021)

Provide targeted interventions as a means of reducing health inequalities in the Roma Communities

Q1 – Q4 Q1 – Q2 Q1- Q4 Q1- Q4 Q3 – Q4 Q1- Q4 Q1- Q4 Q1- Q4

Roma Health Lead & ICH Refugee & Asylum Seeker Lead Roma Health Lead & ICH Refugee & Asylum Seeker Lead Roma Health Lead & ICH Refugee & Asylum Seeker Lead Roma Health Lead & ICH Refugee & Asylum Seeker Lead CH Refugee Asylum Seeker Lead CH Refugee Asylum Seeker Lead Roma Health Lead Roma Health Lead

LGBTI Health Further develop the regional LGBTI

Health Steering Group.

Q1 – Q4

LGBTI Health Lead

48

Support TENI to develop the Adult Module of Gender Identity Skills Training (GIST) and deliver this and GIST in South East Community Healthcare for health service staff.

Deliver LGB Awareness Training for staff.

Develop the South East Community Healthcare LGB Awareness Training

Model as a Train the Trainer Initiative.

Support LGB Ireland to develop an online version of LGB Awareness training.

Q1- Q4

Q1 – Q4 Q1 - Q4 Q3 – Q4 Q1 - Q4

LGBTI Health Lead LGBTI Health Lead& HP&I Sexual Health Lead

Improve health outcomes for the most vulnerable in society including those with addiction issues, the homeless, refugees, asylum seekers and Traveller and Roma communities

Addiction Services

Enhance Governance Structures in Substance Misuse Services

Employment of Assistant Director of Nursing Q3 - Q4 General Manager

Expand availability of naloxone training and distribution within the substance Misuse Service

Q1 - Q4 Substance Misuse Lead

Continue to work with Primary Care and Mental Health services to ensure the needs of service users are being supported in terms of improved access and uptake of mainstream services

Q1- Q4 Substance Misuse Lead

National Drugs Rehabilitation Framework

To continue a programme of training and information provision to staff within the HSE and partner agencies, to support quality service provision across the continuum of care, to include SAOR training, naloxone/overdose prevention training.

To ensure high quality services are provided equitably across the region, which are needs-led, timely and accessible, and which support individual rehabilitation

Expand mental health services for people with substance misuse problems presenting in acute hospitals through the provision of a mental health nurse to provide interventions in hospital and referral pathways to community based addiction services as necessary

To provide effective harm reduction services which are accessible throughout South East Community Healthcare region including needle and syringe programmes, blood borne virus screening, vaccination; as per national Hepatitis C Screening Guidelines 2016 and also in line with the national Hepatitis C treatment programme.

Implementation of the actions from the “Reducing Harm, Supporting Recovery (2017-

Q1 - Q4 Q1 - Q4 Q3 - Q4 Q1 - Q4 Q1 - Q4

Substance Misuse Lead Substance Misuse Lead Substance Misuse Lead Substance Misuse Lead Substance Misuse Lead

49

2025).

Continue to provide and improve access to treatment and rehabilitation services for adults and children, with a particular focus on under 18’s within the Substance Misuse Service.

Improve health outcomes for pregnant women engaged in substance misuse and their babies through enhanced interagency working between Substance Misuse and Maternity Service through the provision of a community based Alcohol & Drug Liaison Midwife.

Q1 - Q4 Q3 - Q4

Substance Misuse Lead Substance Misuse Lead

Continue to implement the National Standards for Safer Better Health Care in Primary Care Substance Misuse Services.

Improve service user outcomes and experience of Substance Misuse Services through Service User Involvement.

Strengthen the capacity of Services to address complex needs of service users by establishing a Care and Case Management group with key stakeholders in each county.

Q1 - Q4 Q1 - Q4 Q1 - Q4

Substance Misuse Lead Substance Misuse Lead Substance Misuse Lead / Regional Rehab Coordinator/Homeless Lead

Continue the Partnership with the Recovery College through the development of co-production training.

Q1 - Q4

Substance Misuse Lead

Provide Traveller Cultural Awareness / competency to Health Service Executive frontline staff

Based on the recommendations of the WIT Evaluation the Traveller Health Coordinator will:

Enhance the training provided by the Traveller Health Projects

Organise the upskilling of existing Traveller Health Workers and train new Travellers as trainers in the new programme

Facilitate the updating of the training manual to a durable, user friendly toolkit to support the roll out of the Traveller Cultural Awareness Trainers when rolling out training.

Work with primary care and other HSE departments to develop targets for Traveller Cultural Competency training.

Work with partners and HSE land to produce an e-learning module

Q1 - Q4 Traveller Health Coordinator

Traveller Health Projects meet their KPI Targets

Traveller Health Coordinator will

ensure that the Section 39 Traveller Health funded organisations will meet their KPI targets and report in a timely manner

Will support the Section 39 Traveller Health funded organisations to do so.

Q1 - Q4 Traveller Health Coordinator

To develop TMHLN Role in line with best practice

The TMHLN will implement the recommendation of the formal evaluation of the post by Trinity

Q1 - Q4 Traveller Health

50

guidelines available

College to inform best practice and positive outcomes for Traveller Mental Health going forward through the Traveller Mental Health Carlow Kilkenny Subgroup of the THU.

The TMHLN will attend relevant training and implement learning and recommendations to support positive mental health where possible.

Continue to work with Primary Care and Mental Health services to ensure the needs of travellers are being supported in terms of improved access and uptake of mainstream services

Coordinator

Ensure Connecting for life training is rolled out for Traveller Health Project Staff

Support the initiatives developed within the South East Community Healthcare Traveller Health Unit on Mental Health and Wellbeing (incorporating ‘little Things’) and collaborate with the Regional Suicide Office and the new Mental Health Service Co-ordinator for Traveller

Q1 - Q4 RLNTH

To feed into the learning on the ground from this area on Traveller Health at a local/regional/National level

The RLNTH will continue to link with other agencies and underpin her work to regional/national strategies

Q1 - Q4 RLNTH

Promote the uptake of

Vaccinations at every life

stage including the

Childhood vaccinations,

HPV and seasonal flu

vaccinations in the

Southeast

The Traveller Health Liaison Nurse will support the Traveller Health Projects to continue to outreach to Traveller to raise Travellers awareness of the childhood vaccination programme through using the information cards from the Travellers Health Chronic Conditions Programme.

Q1 - Q4 RLNTH

Coordination of Chronic Conditions Advisory

The Traveller Health Liaison Nurse will continue to coordinate the Chronic Conditions Advisory Group to oversee advice and support the roll out of the Chronic Conditions Sub Group.

Q1 - Q4 RLNTH

Homeless Rebuilding Ireland Strategy: Continued implementation of the HSE Actions

To continue to work in partnership with the Homeless Action Teams in each local authority area within South East Community Healthcare to ensure they continue to increase their capacity to meet the complex and diverse health and social care needs of homeless people, particularity those with mental health and addiction problems.

In partnership with the Lead Local Authority, to support and facilitate the re-configuration of current Housing First projects into a Regional Housing First Model ensuring standardisation of practice in line with the fidelity of Housing First Principals. This includes the development

Q1 - Q4 Q1- Q4

Regional Rehab Coordinator/ Homeless Lead Regional Rehab Coordinator/ Homeless Lead

51

of a Housing First project in South Tipperary and increase capacity throughout the region through Service Reform Funding.

As part of the Service Reform Funding for Housing First, HSE-Social Inclusion to employ a Senior Psychologist to provide psychological support and interventions as part of the wrap around service provision for the complexities of Housing First service users.

Continue to work with Primary Care and Mental Health services to ensure the needs of homeless persons are being supported in terms of improved access and uptake of mainstream services

Q1 – Q4 Q1 – Q4

Regional Rehab Coordinator/ Homeless Lead Regional Rehab Coordinator/ Homeless Lead

Homeless

National Drugs Strategy – continue implementation of the actions related to Care & Case Management

Further implementation of the National Drugs Rehabilitation Framework across Social Inclusion in the South East Community Healthcare.

Continue to work with and support HSE Care Groups in provision of wrap around health and social care services for homeless persons through integrated shared care plans as per the National Protocols.

Q1 – Q4 Regional Rehab Coordinator/ Homeless Lead

Homeless

Quality Standards

Continue engaging with key stakeholders regarding the implementation of the National Quality Standards for Homeless Services aligned with the National Standards for Safer Better Healthcare

To provide support to Homeless Services in building their capacities to implement quality improvement plans and monitor same.

Q1 – Q4 Regional Rehab Coordinator/ Homeless Lead

Homeless

To continue to support increased capacity, confidence and competency of staff within homeless/ substance misuse services in managing challenging behaviour of complex cases accessing services.

Provide MAPA Train the Trainer event for homeless/substance misuse services to ensure each service has a dedicate MAPA Trainer & Champion to support staff skill in managing potential aggression/violence in the workplace.

Trained trainers will then commence training homeless/substance misuse services staff in MAPA and support implementation of MAPA within these services

Q1 – Q4 Q1 Q2 - Q4

Regional Rehab Coordinator/ Homeless Lead Regional Rehab Coordinator/ Homeless & Substance Misuse Leads

Homeless Improve the health outcome for people experiencing or at risk of homelessness

Q1 – Q4 Reg Rehab Coordinator/ Homeless Lead

52

Section 5 Mental Health Services

Population

The South East Community Healthcare Mental Health Services encompasses the counties of

Carlow, Kilkenny, South Tipperary, Waterford and Wexford. South East Community

Healthcare is the 2nd most deprived region in the country (behind the border region);

Wexford County and Waterford City are respectively remanded 3rd and 6th in the most

deprived areas of the country based on the Pobal HP Relative Deprivation Score, 2011

(Wexford Socio-Economic Baseline Report, April 2015).

Services Provided

In general terms, specialist mental health services are provided to serve a particular group

within the population, based on their stage of life. Child and Adolescent Mental Health

services (CAMHs) serve young people aged up to 18 years, general adult services for those

aged 18 to 64 years and psychiatry of later life provides services for those over 65 years.

Services are provided in a number of different settings including; Community based service

user clinics, acute day services (day hospitals), the individual’s own home, inpatient

facilities. Within South East Community Healthcare, there are 6 approved centres including

two acute adult units, and four Psychiatry of Later Life units. Community Mental Health

Services are delivered by a range of community mental health multi-disciplinary teams using

a sectorised population based approach in line with Vision for Change. Services for people

with enduring mental health illness are provided at day centres, community day services

and a range of low, medium and high support community residences.

South East Community Healthcare Mental Health Services as the statutory service provider

will continue to work with our voluntary partners to ensure the meaningful involvement of

the service user in the design and delivery of our mental health service. This will be

supported by our on-going engagement with a variety of stakeholders including the ongoing

development of area forums to ensure that service users have a voice. In addition, the

ongoing development of Advanced Recovery Ireland and the Recovery College will continue.

In 2019, the role of Area Lead for Mental Health Engagement, in addition to the Peer

Support Worker initiative, will continue to build on the representation of the views of

Service Users, family members and carers towards the ongoing development of a recovery

based mental health service.

The Senior Management Team in South East Community Healthcare Mental Health Services

remains committed to the continued delivery of a high quality service user focused safe

53

service. The focus for 2019 will be on the ongoing review of overall Service Delivery, the

Model of Care and the provision of a safe and effective service in accordance with service

priorities and key performance indicators.


Opportunities Our vision for mental health services is to provide opportunities to support the population

to achieve their optimal mental health through the following key priorities:

Strengthen the Mental Health Service governance arrangements to ensure effective

use of human, financial and infrastructural resources.

Continue with the implementation structures for local action plans within South East

Community Healthcare Mental Health Services aligned to National Connecting for

Life implementation framework with the objective of reducing suicide rates in our

community.

The development of a recovery focused community mental health service will

continue to be an ongoing priority for South East Community Healthcare Mental

Health Services in 2019. This work will be supported by the implementation of the

Service Reform Fund Project/Advancing Recovery Initiatives/Recovery College. In

addition to this South East Community Healthcare Mental Health Services will work

with the Department of Housing, Planning and Local Government regarding the

implementation of the “National Housing Strategy” as it relates to the South East

Community Healthcare residential services.

South East Community Healthcare Mental Health Service will continue with the

implementation of the ‘Best Practice Guidance Framework’ to ensure better

governance in planning and measuring improvements, identifying and addressing

gaps. This work commenced in the approved centres i.e. Department of Psychiatry –

Waterford and Kilkenny in 2018 and this framework will roll out to other service

areas in 2019.

The development of local Area Forums commenced in 2018 and this work will

continue in 2019 to ensure that service users have a voice in the delivery and design

of the Mental Health Services

Training for staff relating to the Mental Health Commission judgement support

framework will continue in 2019. Training will also commence for staff, further to the

requirements of the new Mental Health Commission Centralised Information

System.

The appointment of an additional Psychiatry of Old Age Consultant Psychiatrist in

Carlow/Kilkenny will assist in addressing the challenge presented by the

54

demographic pressures which has seen an increase in the number of referrals to

Psychiatry of Old Age services.

Issues

Challenges for 2019 in Mental Health Services include:

The capacity to recruit and retain a highly-skilled and qualified workforce, particularly in

high-demand health and social care professional/medical and nursing clinical staff.

Lack of Acute Inpatient beds commensurate to meet the clinical needs of the population

and the resultant difficulties created by over occupancy .

Access to appropriate inpatient CAMHs beds/units and out of hours service.

Continued demographic pressures and increasing demand for services will be over and

above the capacities of the planned staffing/resource levels thus impacting on the ability

to deliver services.

Lack of single health care record (HCR) across South East Community Healthcare Mental

Health Services continues to pose risk to the optimum management of service user’s

care. Ways of overcoming this challenge are being explored in advance of the optimum

solution of provision of E-record.

Lack of specialised workforce due to pending retirements in the nursing division which

impacts on our ability to comply with statutory requirements due to shortage of nursing.

Lack of capital infrastructure to support the delivery to a Mental Health Service across

the area.

Delayed discharges from Acute Units for service users who require ongoing

management in specialist supported accommodation.

Financial Risks – in order to maintain existing levels of service, net expenditure in Mental

Health Services is projected to increase, with the main cost drivers:

o Medical and Nursing Agency due to ongoing recruitment difficulties ;

o Revenue and Capital costs arising from legislation/regulation to achieve

compliance ;

o Delayed Discharges from Acute Units for Service Users who require ongoing

management in specialist supported accommodation ;

o Demographic increase with corresponding increased service pressures.

Priorities 2019

The vision for South East Community Healthcare Mental Health Services is to support

service users to achieve their optimal mental health through the following key priorities:

Ensure that the views of service users, family members and carers are central to the

design and delivery of mental health services.

Design integrated, evidence based and recovery focussed Mental Health Services.

55

Deliver timely, clinically effective and standardised safe mental health services in

adherence to statutory requirements.

Enable the provision of mental health services by highly trained and engaged staff

To review the infrastructure requirements of South East Community Healthcare

Mental Health Service and plan for the future.

South East Community Healthcare Mental Health Service works with primary care, acute

hospitals, services for older people, services for people with disabilities, and with a wide

range of non-health sector partners.

South East Community Healthcare Mental Health Services

Carlow/Kilkenny & South Tipperary Mental Health Services

Service No. Provided Service No. Provided

No. of Adult Acute In Service user Beds

44 Psychiatry of Old Age

General Adult POA Acute Inpatient Beds

No. of non acute beds for adults 60 Number of Day Hospitals 0

No. of Day Hospitals 4 No. of Community Mental Health Teams

2

No. of Community Mental Health Teams

8 Number of Day Centres 0

Number of Day Centres 9 Specialist Mental Health Services

No. of High Support Community Residences

12 No. of Rehab and Recovery Teams

2

No. of Low and Medium support Community Residences

12 (11 low and 1 medium)

No. of Liaison Psychiatry Teams

1

CAMHS No. of MHID Teams 0

Number of Inpatient Beds 0 Other 2 Crisis Houses

No. of Day Hospitals 0


4

Waterford/Wexford Mental Health Services

Service No. Provided Service No. Provided

No. of Adult Acute In Service user Beds

44 Psychiatry of Old Age

General Adult POA Acute Inpatient Beds

No. of non acute beds for adults 55 Number of Day Hospitals 0

No. of Day Hospitals 5 No. of Community Mental Health Teams

3


5 Number of Day Centres 0

Number of Day Centres 3 Specialist Mental Health Services

No. of High Support Community Residences

9 No. of Rehab and Recovery Teams

2

56

No. of Low and Medium support Community Residences

16 (1 low and 4 medium)

No. of Liaison Psychiatry Teams

0

CAMHS No. of MHID Teams 0

Number of In Service user Beds 0 Other 1 Respite house

No. of Day Hospitals 0


3



Promoting Mental Health of the population with other services and agencies including reducing the loss of life by suicide

Continue with the implementation structures for local Action Plans within South East Community Healthcare Mental Health Services aligned to national Connecting For Life (CFL) implementation frameworks

Q1 – Q4 General Manager/Regional Suicide Support Officer

Within available resources, The

Regional Suicide Office will deliver a range of training interventions from basic suicide awareness to skills based programmes. Options available include: esuicideTALK, safeTALK, Applied Suicide Intervention Skills Training (ASIST), Understanding Self Harm and Skills Training on Risk Assessment for Self Injury (STORM). The Resource Office for Suicide Prevention (ROSP) will work with the National Office for Suicide Prevention on the roll out of the new National Training Strategy.

Q1 – Q4 General Manager/Regional Suicide Support Officer

Mental Health will continue to work with

Primary Care regarding the development and implementation of the assistant psychology service

Q1 – Q4 Service Manager/Psychology Manager

South East Community Healthcare will

work with the National Youth Mental Health Taskforce to implement agreed actions.

Q4 Head of Service/General Manager/ECD

Design Integrated Evidence Based and Recovery Focused Mental Health Services

Continuation of training of clinicians in Behavioural Family Therapy (BFT) and the development of the standard operational procedure to support the work of the Behavioural Family Therapist.

Q2 Head of Service/General Manager/ECD

57

Continue to roll out the Qbtech ADHD

computerised assessment tool in accordance with available resources

Q3 Service Manager

The development of a recovery focused

community mental health service will be an ongoing priority for South East Community Healthcare Mental Health Services in 2019. This work will be supported by the implementation of the Service Reform Fund Project/Initiatives and will inform the completion of the National Recovery Framework. The Advancing Recovery Initiatives will continue to roll out in 2019 and following significant progress in 2018, the further development of the Recovery College will continue to be a priority in relation to the development of a recovery focus.

Q1 – Q4 General Manager

South East Community Healthcare will

continue to work with Cork Kerry Community Healthcare to operationalise the HSE Standard Operating Procedure to optimise timely access to in-patient beds

Q1 – Q4 Head of Service/ECD

Continue the development of the adult

mental health team with the appointment of a MHID consultant.

Q1 –Q4 Head of Service/Executive Clinical Director

Deliver timely, clinically effective and standardised safe mental health services in adherence to statutory requirements

Expand out of hours responses for General Adult MHS through the development of the 7/7 day hospitals and appointment of agreed new staffing in Waterford

Q1 –Q4 Area Director of Nursing/Executive Clinical Director /Service Manager

Develop a brief and subsequent

business case to support the development of an inpatient unit and a day hospital for CAMHS in South East Community Healthcare

Q1 –Q4 Head of Service/ Executive Clinical Director.

Implement the HSE Incident

Management Framework 2018

Q1 – Q4 Head of Service/ECD/General Manager/Area Directors of Nursing

Continue the implementation of the HSE

“Best Practice Guidance Framework” for Mental Health Services including

Q1 – Q4 Head of Service/ ECD/General Manager/Area

58

development and delivery of training and reporting for Quality Surveillance

Directors of Nursing

Support compliance through monitoring

of services, in collaboration with the Mental health Commission, in order to achieve statutory requirements

Q1 – Q4 Executive Clinical Director/Clinical Directors/Head of Service/General Manager/Area Directors of Nursing

Continue the development of the

Community Mental Health Team’s CAMHs, General Adult and Psychiatry of Later Life Services in accordance with approved new development money/resources

Q1 – Q4 Executive Clinical Director/Head of Service/General Manager

Ensure that the views of service users, family members and carers are central to the design and delivery of mental health services

Improve mental health engagement in the design and delivery of services through the further development of forums in South East Community Healthcare, in conjunction with service users, family members and carers.

Q1-Q4 General Manager/Service Managers/MH Engagement Lead

Develop a standardised approach to

inclusion of service users in care planning and promoting enhanced self-management for service users in line with the recommendations of the National Recovery Framework.

Q1 – Q4 General Manager/Service Managers/MH Engagement Lead

Develop a plan of implementation of the

mental health engagement standards to ensure a consistent national model of engagement by service users and carers.

Q1- Q4 General Manager/Service Managers/MH Engagement Lead

Implement the recently developed

CAMHs advocacy model

Q1 – Q4 General Manager/Service Managers

Continue Roll out for all Staff Recovery

Principle Training

Q1 – Q4 General Manager

Inclusion of Service User representative

on Quality and Patient Safety Committee within the approved centres

Q1 – Q4 General Manager/Service Manager/MH Engagement Lead

Enable the provision of mental health services by highly trained and engaged staff and fit for purpose infrastructure

Develop and implement Workforce Plans for all Disciplines

Q1 – Q4 Head of Service /Executive Clinical Director/General Manager

Progress implementation of the

Q1 – Q4 Area Directors of Nursing/Service

59

postgraduate nursing programme, develop postgraduate non nursing programmes and appoint agreed increased undergraduate nursing numbers to address critical staffing challenges in mental Health nursing

Managers

Commence the design and

implementation of additional quality and performance indicators in mental health service aligned to increased/new services

Q1 – Q4 Head Of Service/Executive Clinical Director/General Manager

Participate in the development of a

HSE-wide programme for the implementation of the assisted decision-making legislation in mental health services delivery


Roll out the agreed minor capital fund to

enhance facilities and infrastructure. Progress plans for major capital development requirement e.g. Replacement of Acute Psychiatric Units


Standardise and move towards more

equitable resource allocation models based on a revised costing model for mental health in line with a Vision for Change and continue the mental health multi-year approach to budgeting


Through the performance management

process, seek to ensure that current resources are utilised in an effective manner which maximises outcomes for service users.


60

Section 6 Disability Services

Population

The rate of disability has risen in Ireland over the last number of years with 13.5% of the

population now reporting at least one disability since 2011 (Census 2016). The rate of

reported disability has risen to 5.9% for those aged 0 to 14 years and 9.3% for those aged 15

to 24 years. This has led to an increased demand across all services for children and young

people. In addition the rate of those aged 65 years and over with a reported disability has

risen to 9.5% since 2011. People are living longer and adults with intellectual disability have

age-related illnesses and conditions. In addition, more people with a disability have more

complex needs. Of people reporting with a disability, the number of people aged 35 years

and over with moderate, severe and profound intellectual disability has increased from

28.5% in 1974 to 49.3% in 2016 (NIDD, 2016).

This change in demographics, increased life expectancy and changing needs for those with

both a physical and sensory disability, and an intellectual disability has led to a significant

increase in the need for disability services across all settings. This includes day supports,

residential and respite services, personal assistant and home support services.

Services Provided

In South East Community Healthcare, there are HSE residential units in South Tipperary,

Wexford and Kilkenny, however, the majority of residential places and all respite and day

services are provided through voluntary and private providers. There are three Section 38

Agencies and over thirty-five Section 39 Residential Agencies. We will work in partnership

with our voluntary and private providers to provide agreed levels of service to this service

user group.

In 2019, South East Community Healthcare will continue to deliver social care supports and

services to people with a disability across the spectrum of day, respite, residential and home

support provision. The financial resources made available to South East Community

Healthcare will present as a challenge owing to financial pressures across Disability Services.


Disability services have a significant programme of reform underway which is informing a

new model of service provision. Transforming Lives sets out the recommendations of the

61

Value for Money and Policy Review of Disability Services in Ireland, 2012. It provides the

framework for the implementation of:

Time to Move on from Congregated Settings – A Strategy for Community Inclusion in

respect of residential centres to support the transition of people from institutional

settings to community-based living.

New Directions Programme is improving day services and supports and aims to meet the

needs of school leavers and those graduating from rehabilitative training.

Implementation of these programmes will enable South East Community Healthcare to

maximise the use of existing resources and develop sustainable models of service provision

with positive outcomes for service users, delivering best value for money and moving

towards an inclusive model of community-based services and supports.

A significant underlying challenge relates to the unmet need for residential and respite care,

which exists in our services. There is a significant demand for unplanned residential places

to respond to the most urgent cases on our waiting list.

At the same time, Disability Services are working to comply with the national standards for

residential care as regulated by HIQA and to maintain registration for all our residential

centres.


Value Improvement Actions

Achieve the required value improvement actions through monitoring of service for Older Persons Services.

Safeguarding

Implement the revised HSE Safeguarding Policy when approved.

Disability Act 2005 – including assessment of need

Reduce the waiting times for assessment of need under the Disability Act 2005 through

the provision of 15 additional posts.

Once agreed nationally implement a Standard Operation Procedure for the Assessment of

Need.

Conclude the recruitment of 11 Children’s Disability Network Posts and implement

Progressing Disability Services for Children and Young People.

62

Residential Services

Progress implementation of Time to Move on from Congregated Settings with a further 15

people with disabilities supported to transition to homes in the community in 2019. This

is subject to funding.

Provide an additional 9 new emergency residential placements.

Continue with the ongoing review of residential placements in line with service

improvement.

Respite Services

Continue to provide 461 people with disabilities, quarterly, with centre-based respite and

alternative innovative models of day respite.

o 13,722 amount of bed nights delivered to 461 amount of people.

o 1,405 day only respite sessions accessed by people with a disability.

Day Services and Supports

Progress implementation of New Directions national policy on the provision of day

services for people with disabilities and strengthen the quality of day service provision

throughout South East Community Healthcare.

Continue to provide adult day services and supports to adults with physical and sensory

disabilities, intellectual disability and autism in South East Community Healthcare.

Provide additional day service supports for approximately 264 school leavers (SL) and

those graduating from rehabilitative training (RT) programmes in 2019 that require a HSE

funded day service.

Continue to implement the interim standards for New Directions through the EASI

(Evaluation, Action and Service Improvement) process commenced in 2018.

PA and Home Support

Continue to deliver home support and PA hours to almost 2,000 people with disabilities.

Provide 564,883 home support and PA hours to alleviate the demand for emergency

residential places. This is above the 2018 target due to under reporting in 2018.

Autism Spectrum Disorder Review

Implement the recommendations arising from the ‘Review of the Health Services for

Individuals with Autism Spectrum Disorder’, carried out in 2017.

63

Personal Budgets Demonstration Project

Roll-out a demonstrator project in South East Community Healthcare in line with the

recommendations “Towards personalised budgets for people with a disability in Ireland”.

Joint HSE and Tusla Interagency Protocol

Continue to support operational roll out of the Joint HSE and Tusla Interagency Protocol,

including internal supporting protocols for CAMHS, Primary Care and Disability through

the dedicated joint workshop sessions.

Children’s Ombudsman (ref: Molly’s Case)

Fully implement recommendations arising from the Children’s Ombudsman report on the

Molly’s Case.

Service Arrangements

Review Part 1 and Part 2 of the service arrangements for section 38 and section 39 service

providers and private providers taking account of the recommendations from the

independent review group set up to examine the role of voluntary organisations in

publicly funded health services.



South East Community Healthcare Social Care will promote health and well-being within care-groups

In particular, social care will meet the MECC targets and will facilitate staff to complete the relevant training.

Q4

GM Disability Services

Provision of and access to day services

Provide additional day service supports for approximately 264 school leavers (SL) and those graduating from rehabilitative training (RT) programmes in 2019 that require a HSE funded day service

Provide updated data regarding all individuals requiring a HSE funded day service in 2019

Advise on the accommodation requirements for new day service entrants 2019.

Coordinate the completion of profile assessments within South East

Q3

Q2

Q2

Q2

Disability Managers and GM for Disability

64

Community Healthcare of all identified SL’s & RT exits requiring HSE funded adult day services in 2019 and submit same to Disability Social Care.

Identify existing capacity within current services that can accommodate new SL’s & RT exits without additional funding.

When notified of the resource being allocated to meet the needs of school leavers, prepare and deliver appropriate service responses with the provider during April and May 2019 so that families can be communicated with before the end of May 2019.

Participate in the validation of the school leaver funding process for 2019.

Update and Maintain current Occupational Guidance Service Database

Q2

Q2

Q3

Q3

Assisted Decision Making

Promote independence of persons with a disability through:

Working in partnership with advocacy services thus ensuring the voice of a person with a disability is heard

Provision of briefing sessions on Assisted Decision Making (Capacity) Act 2015

Prepare an action plan for implementation of Assisted Decision Making (Capacity) legislation.

Q4 HOS-SC and GM – Disability Services

Home Support Ensure that the Home Support Service

is fit for purpose so that it reduces the need for high cost emergency residential care.

Deliver 564,883 home support and PA hours to children and adults

Within existing resources the level and type of support provided is outcome based for the profile of the individual

Target area for 2019 is to review the home support services provided to children aged 8-16 with a high functioning autism across the South East Community Healthcare.

Development of Framework of operating enhanced support as an alternative to residential placements

End of Q3 End of Q4 Q2-Q3 End of Q4

General Manager Disability Services Disability Service Managers GM and Disability Service Managers

65

Home Sharing Project Funded by SRF

Development of a home sharing model of support across the South East Community Healthcare in collaboration with the section 38/39 agencies as per plan agreed with Service Reform fund.

End of Q4 General Manager Disability Services

Management of Residential Care including Emergency Places

In 2019 through the Residential Supports Executive Management Committee and the profile information of the DSMAT continue to discuss and agree economies of scale in managing emergency placements.

Implement new actions as outlined in the revised Residential Support Executive Management framework Version 2 and Guidance for Community Support including New Directions (2019)

Establish the Resource Allocation Group as outlined in the revised Residential Framework (2019)

Q1-Q4 Q1 Q1

GM Disability Services GM Disability Services HOS

Emergency and Support Placements

Provide new emergency and support placements as per the agreed governance process and within the funding allocated.

Q1-Q4 HOS Social Care

Respite Services Participate on the National Taskforce

Oversight Respite Committee

Carry out a review of respite provision in South East Community Healthcare area to inform the development of standard operating protocol for the provision of respite across the South East Community Healthcare area to ensure quality and equity of service and reducing the reliance on emergency residential placements

Establish South East Respite allocation Committee

Agree within the HSE and section 38/39 providers and implement a Standard Operating Protocol for the provision of Respite services

Continue with the provision of respite services across the South East Community Healthcare.

Q1-Q4

Q2 – Q4 Q2 – Q4 Q2 – Q4 Q1 – Q4

Disability GM

Implement Quality & Safety Initiatives

Continue with representation at the Social Care Quality and Safety Committee.

Q1-Q4 HOS Social Care and GM Disability Services

66

Review and analyse incidents (numbers, types, trends)

Ensure the recommendations of any serious investigations are implemented and learning shared to include SRE's/serious incident investigations

Review and analyse complaints (numbers, types, trends)

Provide an active integrated Disabilities Risk Register.

Finalise a Framework for Disability Services

Finalise a Framework for Disability Services to improve the operational delivery of social care services for people with a disability.

The above framework will be finalised with a focus on ensuring that recommendations emanating from varying reports are implemented in full.

Q4

Enhance Governance for Service Arrangements

Further develop enhanced monitoring of service arrangements to ensure that resources are appropriately recorded and deployed

Service Level Arrangements to be finalised and signed as appropriate by 28th February 2019

Q1-Q4

Q1



Grant Aid Agreements to be finalised

and signed as appropriate by 28th February 2019

Q1


Implement Revised Safe Guarding and Protection Policy

Implement the new safeguarding and protection policy

848 staff will be trained in 2019 in the Safeguarding Policy

Safeguarding Committee will deliver on the priority of spreading general awareness of safeguarding throughout the wider community

Q1-Q4

Q1-Q4

Q1-Q4

PSW

PSW

PSW

Recruitment and Retention of Staff within Disability Service to deliver the service in a safe and appropriate manner

Continue to work with HR to expedite recruitment of all existing vacancies within disability Service.

Continue to reduce the over reliance on agency

Ensure that staff working within the disability service understand and have clarity on their role, have the time and the resources to carry out their roles

Q2

Q1-Q4

HOS Social Care and HR , GM

Disability

67

New Directions School Leavers/RT Process

New Funding identified of €224,000 to be utilised to support the implementation of New Directions and the School Leaver process in South East Community Healthcare. This funding is specifically allocated to address the following:-

- Referrals and Guidance

- Profiling and Placement

- Data Collection and Validation.

- Structure and initiatives to advance Interim Standards for New Directions

Develop and Implement a South East Community Healthcare plan in agreement with National Office including the necessary recruitment business case to ensure that New Directions develops in a standardised and consistent manner.

Q1

Q1 – Q4

HOS General Manager Disability Service

Progress implementation of the national policy for reform of the disability services Transforming Lives – the programme for implementing the Value for Money and Policy Review of Disability Services in Ireland, 2012.

Review and reconfigure available staff to work on the development of the NASS and identify any gaps that may impede databases being populated appropriately such as to provide up to date and accurate information for planning purposes.

Continue to participate in the joint housing steering groups with local authorities

Q2

Q1-Q4

Disability GM

Disability GM

Implement time to move on from congregated settings

Support the transfer of 15 service users from institutional settings to community based settings. This is subject to funding.

Work with providers to develop clear, time appropriate action plans to identify how service providers will transition residents from congregated settings into the community in line with policy.

Q4

Q4

Disability Managers and

General Manger for Disability

Services

HIQA Compliance Social Care in the South East will

strengthen working relations with disability providers and will support providers to rank and prioritise quality improvement initiatives within services as such demands arise and having regard to available resources. The outcome of such ranking will ensure that highest risk areas are addressed

Q3

General Manager

– Disability Services

68

as a matter of priority.

Progress Disability Services for Children and Young People (0-18s) Programme

Support the implementation of National Policy on Access to Services for Children with a Disability or Developmental Delay in collaboration with Primary Care with children’s disability network teams as they are established.

Further progress towards reconfiguration of 13 (0-18) Service Teams and support the implementation of the programme. To achieve this, South East Community Healthcare is establishing a Cross Sectoral Children’s Services Forum to deliver an integrated approach to reconfiguration.

Implement the National Access Policy in collaboration with primary care to ensure one clear pathway of access for all children with a disability into their local services.

Set up a joint Primary Care/Social Care implementation plan for the NAP

Evaluate the effectiveness of the national policy on access to services for children with a disability or developmental delay in collaboration with primary care

Implement the new procedures in relation to the Assessment of Need under the Disability Act

Q1-Q4

Q1-Q4

Q1-Q4

Head of Social Care

GM Disability Services &

Project Manager

Head of Social Care & Head of Primary Care

Centralisation of the Assessment of Need Office

Commence reassignment of the backlog stage 1 applications (143) across the South East Community Healthcare

Scope the project plan for a centralised application system within the South East Community Healthcare subject to available resources

End of Q4

Q1-Q4

GM Disability Services/Project

Manager, Progressing

Disability Services

Continuation of implementation of Joint TUSLA-HSE protocol

Continue with implementation of the joint protocol as agreed with TUSLA. Embed the terms of reference and develop procedures and pathways for engagement and escalation

As part of implementing the joint protocol, South East Community Healthcare social care will undertake an assessment of need of children with a moderate to high level of disability currently within foster care within the South East

Q1-Q4

Head of Social Care & General

Manager Disability Services

69

Participate in roll out of the Neuro-Rehabilitation Strategy

Identify resource available within South East Community Healthcare that can be aligned to the implementation of the Neuro-Rehabilitation Strategy

Q4

Disability GM

70

Section 7 Older Persons & Palliative

Care Services

Population

The biggest increase in Ireland’s population is within the older age groups. The 2016 Census

showed a significant increase of 18.3% in the population of those aged 65 years and older in

South East Community Healthcare compared to 2011. Over the same time period the number

of people aged 85 and over in South East Community Healthcare increased by 14%.

This increase in the older persons’ population is welcome; it is an acknowledgment of

improved health and greater longevity. It brings opportunities as well as presenting the

challenge to ensure that health and social care services can be delivered at adequate levels, in

an integrated manner to meet or support the needs of older people. It is also important to

acknowledge the role of carers in the context of their support to older people.

The table illustrates the population of those aged 65 years and older in South East Community

Healthcare.

Area Aged 65-69 Aged 70-74 Aged 75-79 Aged 80-84 Aged 85+ Total

Carlow Kilkenny 6218 4798 3333 2340 2028 18717

South Tipperary 4727 3640 2636 1881 1544 14428

Waterford 6285 4990 3540 2464 1893 19172

Wexford 7265 5791 4151 2693 2085 21985

TOTAL 24,495 19,219 13,660 9,378 7,550 74,302

Services Provided

Older persons’ services are delivered through a community-based approach, supporting

older people to live in their own homes and communities and, when needed, high quality

residential care will also be provided. A wide range of services are provided including home

supports, short stay and long stay residential care, transitional care and day care, through

HSE direct provision and through voluntary and private providers.


South East Community Healthcare Older Persons Services will continue to further develop and

implement the Integrated Care Programmes for Older Persons (ICPOP) in Carlow/Kilkenny,

South Tipperary, Waterford and Wexford in 2019.

71

In conjunction with HSE Estates, South East Community Healthcare Older Persons Services will

continue to engage in the advancement of the Community Nursing Units Public Private

Partnership Project.


Value Improvement Actions

Achieve the required value improvement actions through monitoring of service for

Older Persons Services.

Home Support

The single Funding Model of Home Support commenced in 2018 will be further

embedded in 2019 with a particular focus on strengthening governance,

management capability, quality, and reliability.

The revised 2018 contract for HSE Home Support staff will be implemented in 2019.

Provide home support of 1.95 million hours to an average of 6115 people, at any one

time.

NHSS/Residential and HSE Public Units

Continue to provide Nursing Home Support Scheme funding to 520 long term public

and private residential places in 2019.

Continue to implement a national target wait time of no greater than 4 weeks for

funding approval.

Support the reconfiguration of local NHSS offices in line with the national plan to

develop 4 regional offices.

Continue the implementation of the 2016-2021 Capital Plan for public residential units

with colleagues in HSE Estates and the National PPP Office to ensure maximum

regulatory compliance of our built environment by the critical regulatory date of 2021.

The use of Transitional Care Funding as an enabler to hospital discharge for those who

are indicated as requiring long stay care and those requiring post acute convalescence

on their journey home will be maximised with an envisaged benefit of up to 42 people

per week.

Dementia

Continue to support people with dementia through the memory technology resource

rooms in 7 sites in the South East.

72

Provide 2 day training to home support staff in dementia specifically to HSCAs working

with people with dementia.

Implement the learnings and outcomes from the HSE / Genio-supported dementia

specific initiatives which focus on personalised and flexible approaches to care.

Day Care and Community Supports

Continue to provide HSE day care services to support older people.

Continue to provide a broad range of other community and voluntary services

including, meals on wheels, social satellite services, befriending services etc. to older

people in South East Community Healthcare through section 39 grants.

Continue to progress development of a telephone contact befriending service.

Provide support to existing supported care home services to maintain existing services

in accordance with HIQA regulations using additional funding allocated at the end of

2018.

Safeguarding

Implement the revised HSE Safeguarding Policy when approved.

Integrated Care Programme for Older Persons

Continue to support and develop the Integrated Care Programmes for Older Persons

(ICPOP) in Carlow/Kilkenny, South Tipperary, Waterford and Wexford in 2019.

Develop and foster working relationships with the Age Friendly Alliances in each

county.

Falls Prevention and Bone Health

Progress the AFFINITY and Bone Health programme across all services in developing an

integrated approach to the prevention and management of falls.

Falls working group established on preventing falls in residential units.

Single Assessment Tool

Implementation of the Single Assessment Tool (SAT) will continue as a focus with

recognised implementation challenges.

73

Implementing Priorities in 2019 Priority Priority Action Timeline Lead

Home Support Deliver 1.95 million home support hours in


Q1-Q4 GM Older Persons Services

Deliver Home Support to 6115 older

people in South East Community Healthcare at any time to enable them to return to, or remain at home for as long as appropriate to their needs.


Continue to provide dedicated home

supports and transitional care to acute hospitals as part of the winter measures. (40 additional packages for South East Community Healthcare as part of the Winter Plan)


Commence audit reviews of home support

services to ensure standardised practices are in place.


Implement the single funding model for

home support services and improve quality of service through review and audit


Nursing Homes Support Scheme

Continue to support the Nursing Homes Support Scheme


Continue to implement a national target

wait time of no greater than 4 weeks for funding approval


Residential Services Ensure effective implementation of

recommendations arising from HIQA inspections in designated centres.


Continue implementation of Capital Plan

for public residential units with colleagues in HSE Estates and the National PPP Office to ensure HIQA compliance

Q1- Q4 GM Older Persons Services

Aim for an occupancy target of 90% in

short stay beds

End of Q4 GM Older Persons Services

Dementia Continue to communicate key messages

of the Understand Together campaign

Q1-Q4

GM Older Persons Services

On-going delivery of Intensive Homecare

Packages for People with Dementia

Q1-Q4

GM Older Persons Services

74

Continue a process for the design and

delivery of personalised intensive homecare packages to people with dementia in:

- Waterford

- South Tipperary


Support ongoing education across the

community and acute settings including workshops/online modules and educational awareness programmes

Q1–Q4 GM Older Persons Services

Continue to support memory clinics

across South East Community Healthcare


Continue to support the Memory

Technology Resource Rooms (MTRRs) in the 7 sites across South East Community Healthcare


Train 8 trainers to roll out 2 day training in

dementia care specifically to HSCAs working with people with dementia.


Train 100 HSCAs working with people

with dementia


Day Care and Community Supports

Continue to provide HSE day care services to support older people.


Continue to provide a broad range of

other community and voluntary services including, meals on wheels, social satellite services, befriending services etc. to older people in South East Community Healthcare through section 39 grants.


Integrated Care Programme for Older Persons (ICPOP)

Continue to support and develop the four ICPOP programmes

Q1- Q4 GM Older Persons Services

Falls Prevention and Bone Health

Continue to progress the actions of the Falls Working Group across HSE residential units in order to minimise and reduce falls


National Carers’ Strategy 2012

Continue to consult with the Older Persons Councils/Age Friendly County programme in the continued development of carer’s supports.


Quality and Safety Conduct Quality & Safety walk arounds in

each of the HSE Residential Units

Q1-Q4 GM Older Persons

75

Services

Continue to support Residents Councils,

Family Forums, Service User Panels.


Continue to review and analyse incidents

(numbers, types, trends)


Ensure that the recommendations of any

serious investigations are implemented and learning shared to include SRE's/serious incident investigations


Continue to review and analysis of

complaints (numbers, types, trends)


Maintain an active Older Persons

Services Risk Register


Older Persons Services Quality and

Safety Committee will continue to ensure that recommendations from incident investigations, reviews, inspection reports and other sources of best practice are implemented and audited for effectiveness across the care group


Review the trends from the collation of

HIQA Notification Forms submitted by HSE provided-services


Single Assessment Tool (SAT)

Progress implementation of SAT for assessment of care needs for older people seeking access to community care and long stay residential care.


Service Arrangements Service Arrangements to be finalised and

signed appropriate by 28th February 2019

Q2 GM Older Persons Services

Grant Aid Agreements to be finalised and

signed as appropriate by 28th February 2019

Q2 GM Older Persons Services

Safeguarding

Implement the new safeguarding and protection policy

848 staff will be trained in 2019 in the Safeguarding Policy

Safeguarding Committee will deliver on the priority of spreading general awareness of safeguarding throughout the wider community

Q1-Q4

Q1-Q4

Q1-Q4

PSW

PSW

PSW

76

Palliative Care Services

Palliative Care Services Provided

The aim of palliative care is to enhance quality of life for patients suffering from life-limiting

conditions and, wherever possible, to positively influence the course of illness with a focus on

the prevention and relief of suffering by means of assessing and treating pain and other

physical, psychosocial or spiritual problems. Palliative Care also extends support to families to

help them cope with their family member’s illness and their own experience of grief and loss.

Demand for palliative care services is growing as the population ages and rates of invasive

cancers and other chronic life limiting conditions such as heart disease, respiratory conditions

and dementia continue to rise. It is estimated that 50% of deaths from non-cancer conditions,

such as heart disease, respiratory disease, cerebrovascular disease and dementia can benefit

from palliative care support.

Palliative Care in Southeast Community Healthcare is currently provided by consultant led

specialist teams, both acute and community, in each county of Waterford, Wexford, Carlow,

Kilkenny and South Tipperary. These teams consist of Consultants in Palliative Medicine,

Non Consultant Hospital Doctors, Clinical Nurse Specialists and Occupational Therapists. This

specialist service aims to provide supports in a place of the service user’s choice whenever

clinically possible. At any one time approximately 400 Service Users access Community

Specialist Palliative Care Services across the South East.


Commissioning of our new Regional Specialist Palliative Care Centre at University Hospital

Waterford provides significant scope to drive a fully integrated approach to the delivery of

Consultant Led Specialist Palliative Services across Acute/In-Service user/Community Nursing

Units/Service users Homes. Clear clinical and operational governance arrangements across

Specialist Palliative Care Units and existing Community Specialist Palliative Care Nursing

Services are now required to optimise the palliative care services model in the South East.

Implementation of Standards for Safer Better HealthCare within Community Specialist

Palliative Care Services throughout the South East also provides opportunity for service

improvement. While national policy indicates that all Palliative Care Service should be funded

by the state, service provision in the South East continues to be challenged by complex service

funding arrangements whereby statutory funding to Voluntary Hospice Movements currently

stands at 35%.

77

Priorities

Expand the provision of Consultant led specialist palliative care services in the South

East in 2019 optimising an integrated service model approach.

Commence the implementation of the National Clinical Programme for Palliative Care,

Model of Care

Continue the implementation of the Palliative Care Services – Three Year Development

Framework 2017-2019.

Continue to partner local voluntary organisations to improve access to quality care in

the community.

Implementing Priorities in 2019 Priority Priority Action Timeline Lead

Opening of Regional Inpatient Specialist Palliative Care Unit

Complete commissioning of building by end of Q2 2019

Develop Recruitment plan for Unit.

Waterford Community Specialist Palliative care team (SPCT) to commence operating from building

Phased opening of inpatient unit beds to commence in Q4 2019.

Develop and implement an agreement between South East Community Healthcare and University Hospital Waterford in relation to corporate and clinical governance of shared services for the unit.

Q2

Q2

Q3

Q4

Q1 – Q3

Primary Care General Manager Waterford/Wexford

Governance structure for Community Specialist Palliative Care Teams across South East Community Healthcare

Engage with Hospice committees/ movements to integrate Clinical Nurse Specialist and Clinical Nurse Managers 3 into the regional Nursing governance structure for Specialist Palliative Care services

Q2 - 4 Primary Care Director of Nursing, General Manager Waterford/Wexford.

Development of Regional Palliative Care partnership forum between HSE and Hospice movements / committees

Secure appropriate membership of forum to include Hospice Movements/ Committees/ Service User/ HSE to advise on the ethos and operations of the Specialist Palliative Care Service

Q3-Q4 Primary Care Director of Nursing, General Manager Waterford/Wexford

Implement Palliative Care Outcomes Collaboration (PCOC) documentation, assessment tools and data collection as the method to drive ongoing quality improvement.

Commence implementation of PCOC by Waterford Specialist Palliative Care Team (SPCT) and assess suitability to implement PCOC for IPU

Q1- Q4 Primary Care Waterford PCOC steering committee

78

Commence streamlining of PPPGs and documentation across 4 Community Specialist Palliative Care Teams

Develop and implement a Regional Medication Management Procedure

Standardise medication management documentation used in the home throughout SPC in South East Community Healthcare

Q2 - Q3

Primary Care Director of Nursing

79

Section 8 Workforce

Workforce

Workforce Position

Government policy on public service numbers and costs (pay and non-pay) is focused on

ensuring that the health workforce operates within the approved pay budgets and WTE

level. South East Community Healthcare (SECH) manages a WTE of 5,231wte (Statutory and

Voluntary December 2018 figure – Source – Health Service Personnel Census).


(SECH)

WTE December 2018

Overall 5,231

HSE (SECH) 4,171

Section 38s (Voluntary Agencies) 1,060

Health Services People Strategy 2019-2024

The health sector’s workforce is at the core of the delivery of healthcare services working

across and within all care settings in communities, hospitals and healthcare offices. Building

on progress made to date; the health service will continue to nurture, support and develop

a workforce that is caring, dedicated to excellence, welcomes change and innovation,

embraces leadership and teamwork, fosters inclusiveness and diversity and maintains

continuous professional development and learning. The People Strategy 2019-2024 has

been developed in recognition of the vital role our workforce plays in delivering safer better

healthcare. This strategy placed emphasis on Leadership, Talent Capability enabling people

and culture change and a key tenet underpinning its implementation is the commitment to

engage, develop, value and support the workforce and deliver the Sláintecare vision.

Recruiting and retaining motivated staff remains of paramount importance in the continued

delivery of health services to an increasing and changing demographic population. The

challenges in relation to the ongoing recruitment and retention of staff is even more

significant in the context of the Health Reform Programme which will require significant

80

change management, organisation re-design and organisational development support in

order to become a reality.

2019 Key Priorities for Human Resources:

Subject to available resources South East Community Healthcare will continue

developing the HR operating model by building on the work to date undertaken with

PwC and the Heads of HR across the 9 CHOs with regard to national discussions on

CHO implementation and the implementation of SláinteCare.

A key priority for South East Community Healthcare is the implementation of the National

Integrated Staff Records & Pay Programme (NiSRP) in South East Community Healthcare.

Continue to support and contribute to the further development of staff engagement

as a core organisational priority and as a foundation for improved performance. A

series of workshops will be arranged with staff in Q2 on the Staff Survey 2018 to

feedback on the results and to identify and explore actions with managers and staff

to address the findings. Staff health and wellbeing will be a key focus in 2019 in

progressing the engagement agenda.

Work in collaboration with colleagues in Heath and Well Being and Health and Safety

in ensuring that support and assistance is provided during the roll out of the pilot

WorkPositiveCI survey in Q1 of 2019 with a view to commencing implementation of

action plans in relation to Work Positive across all services in 2019.

Work with Health Business Services (HBS) to attract, recruit and retain staff.

Continued commitment to Public Service Stability Agreement 2018-2020 including

support for the work of the Public Service Pay Commission and implementation of

recommendations where relevant.

Implementation of Consultant Contract 2008 Settlement Agreement and consultant

contract compliance arrangements.

On-going implementation of WRC nursing and midwifery recruitment and retention

agreement and ED agreement.

In conjunction with Learning, Education and Talent Development (LETD) develop and

provide relevant training across all disciplines and grades within South East

Community Healthcare.

81

Implementation of Working Together for Health – A National Strategic Framework

for Health and Social Care Workforce Planning.

Implementation of the Strategic Review of Medical Training and Career Structure

(MacCraith Report).

Pay and Staffing Strategy 2018 and Funded Workforce Plans

The 2019 Pay and Staffing Strategy is a continuation of the paybill strategy which has been

in place for a number of years and is central to continued compliance with allocated WTE

and expenditure budgets. 2019 will be extremely challenging given the WTE employment

limits and budgetary situation. Pay expenditure, which is made up of direct employment

costs, overtime and agency, will continue to be robustly monitored, managed and controlled

to ensure compliance with allocated pay budgets and WTE employment limits.

A key objective in 2019 will be to focus on reducing and controlling pay costs, including

agency and overtime, and implementation of cost containment plans. This is in addition to

maximising the performance and productivity of the health workforce. An assessment of

agency use to determine scope for its reduction will be undertaken in Q1 and Q2 across all

Care Groups and plans will be agreed to address the findings.

Operate strictly within allocated pay frameworks, while ensuring that services are

maintained to the maximum extent and that the service priorities determined by

Government are addressed.

Comply strictly with public sector pay policy and public sector appointments.

Continue to robustly manage Attendance Management in line with the provisions of the

relevant HSE policies and procedures.

Leadership, Education, Talent and Development

In consultation with Leadership, Education, Talent and Development (LETD) South East

Community Healthcare will continue to support staff development to ensure an appropriate

qualified and developed workforce who can deliver our organisational goals whilst

developing their talent and capability thus aiding staff retention. In consultation with LETD

we will provide a leadership, education and development plan for South East Community

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Healthcare to build capacity of staff in the South East to meet the organisational

requirements. The LED priorities in respect of 2019 will be agreed with LETD and will in part

be contingent on available funding.

Enhancing Nursing Services

Strategic leadership and workforce development is supported by education and training, safe

clinical evidence-based practice, a consistent and standardised approach, avoidance of

duplication of effort while supporting legal and regulatory requirements at all levels. Key

priorities in 2019 include:

Strengthen the capacity of nurses and teams to meet the healthcare and wellbeing needs of

the population through collaboration on policy, regulatory, professional and education

matters, leadership, professional development, educational sponsorship, workforce planning,

role expansion, effective communication, informatics and professional support.

Support and progress initiatives, including the roll-out of the Framework for Staffing and Skill

Mix for Nursing (phase 1 and 2);

Support nurses to participate in programmes to prepare for advanced practitioner roles.

Support nurses in education programmes

Health and Social Care Professions

Health and Social Care Professions (HSCP) refer to 25 groups of professionals who provide

services which impact on the health, wellbeing and quality of life of people. The HSCP workforce

includes therapists, social workers, psychologists, orthoptists, audiologists and dieticians among

others. The services in which they work include community and primary care, mental health,

older persons’, disability and residential services and acute hospitals. Key priorities in 2019

include:

Support National HSCP Office to implement the priority actions outlined in the HSCP

Education and Development Strategy 2016-2019, within South East Community Healthcare

Support managers to strengthen and support evidence-based HSCP practice.

83

Workforce Planning

The DoH published a National Strategic Framework for Health Workforce Planning –

Working Together for Health in 2017, providing an integrated, dynamic and multi-

disciplinary approach to workforce planning at all levels of the health service. We will work

with National HR on the implementation of the strategic framework as it applies to our CHO

and to further the workforce planning goals in the revised People Strategy.

European Working Time Directive

South East Community Healthcare is committed to maintaining and progressing continued

compliance with the requirements of the European Working Time Act for both non-consultant

hospital doctors (NCHDs) and staff in the social care sector. Key indicators of performance

agreed with the European Commission include a maximum 24 hour shift, maximum average 48

hour week; 30 minute breaks every six hours, 11 hour daily rest / equivalent compensatory rest

and 35 hour weekly / 59 hour fortnightly / equivalent compensatory rest. Performance in

relation to the measures is monitored on a regular basis.

HR System / Human Resource Professional Services

A key priority for 2019 is the implementation of the National Integrated Staff Records and

Pay Programme (NiSRP) within South East Community Healthcare.

NiSRP will modernise the way South East Community Healthcare connects with staff,

improving access for them to their staff record and pay details via online employee and

manager self-service.

The potential benefits of full implementation of NiSRP include

o Single Staff Records technical system that will give full coverage of all South

East Community Healthcare service staff related data.

o Single payroll technical platform linked to the staff records system which will

give full costs for staff internal and agency hour by hour leading to better

workforce analysis and planning.

o Full staff service history from a current date which will improve pension

services into the future.

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o A direct link between on line time returns and payroll will eliminate the

amount of time spent checking and validating manual returns.

o Employee & Manager Self Service will make the staff records service more

accessible and help ensure the information on file is more accurate. Staff will

be able to check their record to ensure it is accurate and complete and

arrange to have it changed if necessary.

National Workplace Investigations Unit

South East Community Healthcare will continue to work with the National Workplace

Investigations Unit to improve the investigations process in our CHO and ensure that

suitable nominees attend the training provided.

People’s Needs Defining Change - Health Services Change Guide

People’s Needs Defining Change is the policy framework and agreed approach to change

signed off by HSE Leadership and the Joint Information and Consultation Forum

representing the trade unions. It presents the overarching Change Framework that connects

and enables a whole system approach to delivering change across the system and is a key

foundation for delivering the people and culture change required to implement Sláintecare

and Public Sector Reform. The Change Guide complements all of the other service, quality

and culture change programmes that are currently making progress towards the delivery of

person-centred care, underpinned by our values of Care, Compassion, Trust and Learning

and can be applied at all levels to support managers and staff to mobilise and implement

change. Building this capacity will enable and support staff to work with and embrace

change as an enabler of better outcomes for service users, families, citizens and local

communities. The guide is available on www.hse.ie/changeguide

Wellbeing and Engagement

South East Community Healthcare will continue to work with Health & Wellbeing, Occupational

Health, EAP and Health & Safety in ensuring all staff can avail of the full range of support

services. Appropriate case management will be supported which will assist in preventing illness

http://www.hse.ie/changeguide

85

or injury at work. South East Community Healthcare will continue to build on initiatives

commenced in the 2018 in relation to:

Providing opportunities for staff and managers to build capacity and resilience at

individual, team and organisational level

Growing and develop leadership skills among all our staff, through coaching,

personal development and training.

Supporting the implementation of the findings from staff surveys and consultation

workshops / events related to staff health & wellbeing

Supporting and leading out as appropriate on behalf of South East Community

Healthcare on recommendations from key pieces of work underway in HSE e.g.

WorkPositiveCI, Cultural Survey and Staff Survey etc.

Mapping, maintain and disseminate information in relation to services, supports and

activities available to staff

To work in partnership with our colleagues, locally and nationally in developing a

sustainable supportive culture in our organisation.

Code of Conduct for Health and Social Service Providers

South East Community Healthcare will ensure adherence to Supporting a Culture of Safety,

Quality and Kindness: A Code of Conduct for Health and Social Service Providers 2018. This

will ensure the safety of those accessing services whilst supporting our staff in providing

safe services.

Risks

There are staffing risks that may impact on the capacity of South East Community

Healthcare to achieve the ambitions set out in this Plan. The constraints that will apply

arising from the need to remain within WTE and affordability limits will put pressure on the

capacity of the system to deliver safer health and social care services with the resources

that are available.

The impact of the constrained recruitment environment over the last decade has resulted in

an ageing workforce profile. This is likely to continue to be the reality for the immediate

future and brings with it potential risks for staff given the complex and diverse operating

environment.

86

Section 9 Finance & Value

Improvement Programme Summary

South East Community Healthcare was assigned a budget of €474.62m in 2019 which is a €10.42m / 2.1% year on year budget reduction versus the 2018 closing budget of €485.04m. This budget is required to cover services to be delivered through the year including the impacts of -

National pay agreements (primarily public sector-wide).

Increases in drugs and other clinical non-pay costs including health technology innovations.

Inflation-related price increases

Full year cost of services commenced in 2018

Additional service activity to meet demographic pressures.

Financial challenge 2019

A best estimate of the Financial Challenge for 2019 is €22.3m before national coverage. Nationally, the HSE have adopted a range of actions / initiatives to address the financial challenge in 2019 and the key measures that will be adopted in the South East include but are not limited to -

South East Community Healthcare - 2019 Pay Non Pay Gross Budget Income Net Budget

Division Care Group €m €m €m €m €m

Primary Care Primary Care Direct 56.53 29.66 86.20 -1.42 84.78

Social Inclusion 2.92 6.22 9.15 0.00 9.14

Palliative Care 0.18 1.25 1.44 0.00 1.44

Local Demand Led 0.00 18.53 18.53 0.00 18.53

CHO 5 Corp, PMO & QPS 0.87 0.04 0.91 0.00 0.91

Primary Care Total 60.51 55.71 116.22 -1.42 114.80

Mental Health 83.52 17.51 101.03 -1.98 99.05

Mental Health Care Total 83.52 17.51 101.03 -1.98 99.05

Social Care Disability 23.76 156.34 180.10 -0.44 179.66

Older Persons 84.78 35.40 120.18 -39.06 81.12

Social Care Total 108.54 191.74 300.28 -39.50 260.77

CHO 5 Total 252.57 264.96 517.53 -42.91 474.62

87

Procurement – Reduction in costs via contracting

Overhead and other non-pay efficiencies

Agency/Overtime conversion

Vacancy control i.e. prioritisation of frontline staff replacement within pay budgets

Vacancy control community voluntary organisations

Disability – Department of Health to agree HIQA compliance phased investment

programme 2019 to 2021 – provision limited to €2.6m for 2019

High cost community residential care including external placements – centralised

procurement and co-ordination

Reconfigure the overall bed stock to a more sustainable level giving rise to a possible

reduction in bed numbers

In addition to the range of specific actions / initiatives listed above, and following review at leadership team level, the HSE will seek, notwithstanding the delivery and other risks already being managed within the plan, to secure additional savings by further evaluation of potential opportunities in the following areas:

Reduction in absenteeism rates in addition to measures already assumed

Further stock and logistics efficiencies

Reduction in low value / no value care

Further prioritisation of staff travel

Additional modernisation and prioritisation of training and development

Community income

Risks to Operational Service Areas resulting from 2019 Funding Position

South East Community Healthcare has modelled the expected level of activity that the 2019 funding will cover and identified service areas where the HSE is expected to address service demands beyond its funding envelope. It has looked at what cost savings can be made and has also assessed the costs that cannot be avoided or are fixed. In the case of some services, given that the HSE is the statutory provider of last resort and the realities around the relatively fixed nature of certain costs, there is often pressure to respond to need even if this exceeds the available funding level.

Disabilities - Funding Challenge of €11m and impacts are –

Emergency Residential Placements - An inability to provide for Emergency

Residential Placements resulting in risk to vulnerable adults and children. These

arise due to safeguarding, health and safety concerns etc

Inability to meet legal requirements and unmet need

Home Support and PA Service – Non-recycling of hours will result in lack of service

for a significant number of vulnerable adults and children with disabilities across the

South East.

Transport of Service Users

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Assessment of Need

Decongregation – plans will be delayed as a result of funding shortage

Section 38 and 39 Agencies may see their funding curtailed

Older Persons – Funding Challenge of €3.2m (before national coverage) and key impacts are -

Inadequate provision of home support which will lead to increased waiting lists,

failure to assist acute hospitals discharges, risks to vulnerable adults, safeguarding

and health and safety risks.

Reconfiguration and potential closure of beds which will result in failure to assist

acute hospital discharges.

Primary Care (excluding Demand Led) – Funding Challenge of €1.3m (before national coverage) and key impacts are –

Aids and Appliances: This continues to be the main area of deficit in Primary Care.

Spend is driven by the increasing pressure from Acute Services to facilitate hospital

avoidance and early discharges. A curtailment on spend will significantly impact on

discharges from the acute hospital sector and the ability to maintain service users

within their own home.

Therapies:

o Due to the lack of additional funding and the curtailment of the employment

of agency the already lengthy waiting times for all therapies across all

Southeast Primary Care will continue to increase.

o Lack of approval to backfill critical front line maternity leaves will impact on

placements for UCC students which heretofore were accommodated.

Psychology: Due to the lack of additional funding and the curtailment of the employment of agency will impact on waiting times and the availability to see clients within the Primary Care Setting.

Orthodontics: Currently there is an extremely challenging position in relation to the

provision of orthodontics with wait times of up to 4 years.

Paediatric Home Care Packages: The provision of comprehensive Paediatric Home

Care Packages will be a major challenge in 2019. For the safe provision of clinical

services, it is not feasible to directly curtail this service.

Social Inclusion – Interpreter expenses: South East Primary Care have seen a

significant increase in the requirement for interpreter services. In 2018 there was a

significant deficit and it is expected that this will increase further in 2019 with the

allocation of additional refugees and asylum seekers.

Palliative Care: The lack of funding for the new palliative care unit at University

Hospital Waterford will mean that the unit cannot open in line with previous targets.

89

The dedicated Project Manager Post will not be appointed which will impact on the

preparation for opening.

Maintenance: There has been significant control of costs in the areas of building

maintenance, decorating and furnishings to the extent that many facilities are in

need of refurbishment and if continued will not comply with required standards.

Mental Health - Funding Challenge of €6.7m (before Time Related Savings and funded developments) and key impacts are –

Reduced capacity to recruit and retain a highly-skilled and qualified workforce,

particularly in high-demand health and social care professional/medical and nursing

clinical staff.

Lack of Acute Inpatient beds to meet the clinical needs of the population and the

resultant difficulties created by over occupancy

Timely access to appropriate inpatient CAMHs beds/units and out of hours service.

Continued demographic pressures and increasing demand for services will be over

and above the capacities of the planned staffing/resource levels thus impacting on

the ability to deliver services.

Lack of adequate infrastructure to support the delivery of services across the area.

Delayed discharges from Acute Units for service users who require ongoing

management in specialist supported accommodation

Lack of increased resources (clinical and nonclinical) to comply with regulations.

.

Health & Well Being - key impacts of funding challenge are –

Insufficient investment in chronic disease programmes

Threats to general population health and wellbeing through lack of infectious

disease control, immunisation, and environmental health services.

Impact on HSE staff health and wellbeing

Value Improvement Programme

The Value Improvement Programme (VIP) commenced in 2018 responding to the requirements laid out in NSP2018 to support services and corporate units in realising cash savings, improvements in efficiency and service effectiveness. Value Improvement for NSP2019 will be a more balanced approach across the four aims at the core of the programme, population health, patient experience, per capita cost and staff experience. VIP is a multi-year programme, reaching beyond what could be perceived as purely cost saving measures and will deliver on all four aims. The key underpinning principle of the Programme is that value does not come at the expense of service quantum or quality.

90

Indeed, the goal is to improve quality and quantum by driving efficiency and effectiveness equally. The National VIP Team will assist project teams in identifying the value improvement opportunities, verifying their validity and measuring and reporting the value gained.

Finance – Supporting Service Delivery

Finance provides strategic and operational financial support, direction and advice to services within the HSE to achieve the organisational goals of providing high quality, integrated health and personal social services. The objectives of the finance team are to support the HSE to secure and account for the maximum appropriate investment in health and social care and to support our services to deliver and demonstrate value for money in the widest sense of that phrase (including safe, effective and efficient services).

Finance Department Priorities for 2019

Prepare for the implementation of a single national financial and procurement system (IFMS) by standardising and streamlining finance processes

Improve reporting and budgeting capacity by repointing of the existing Finance Staff Resources to focus on specific Care Groups

Review of Skill Mix in Residential Units and implementation of recommendations

Improve controls and compliance

Pay Bill Management – working with HR and the Service Divisions on the continued development of an integrated strategy in respect of recruitment, agency conversion and workforce planning in 2019.

Continued development of Corporate Procurement Compliance Plan as part of the National Compliance Improvement Programme (CIP).

91

Appendices

KPI Targets (CHO 5) South East Community Healthcare

KPI’s Primary Care ......................................................................................................................................................................................................................................

KPI Social Inclusion .....................................................................................................................................................................................................................................

KPI’s Palliative Care ....................................................................................................................................................................................................................................

KPI’s Mental Health .....................................................................................................................................................................................................................................

KPI’s Disability Services ..............................................................................................................................................................................................................................

KPI’s Older Persons Services .......................................................................................................................................................................................................................

KPI’s Health & Wellbeing .............................................................................................................................................................................................................................

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KPI’s Primary Care

Key Performance Indicators Service Planning 2019

2018 2018 2019

2019 Expected Activity /

Target

KPI Title NSP/ OP Performance

Area Reporting

Period

2018 National Target /

Expected Activity

2018 Projected outturn


Expected Activity

Reported at National/ CHO / HG

CHO 5

Community Diagnostics (Privately Provided Service)

No. of ultrasound referrals accepted

Access and Integration

M 20,278 23,290 CHO No

Service

No. of ultrasound examinations undertaken


M 20,278 24,168 CHO No

Service

Community Intervention Teams Referrals by referral category

38,180 43,084 45,432 6,468

Admission Avoidance (includes OPAT) NSP Quality and

Safety M 1,186 609 1,380 CHO 288

Hospital Avoidance NSP Quality and

Safety M 28,417 34,090 33,180 CHO 5,076

Early discharge (includes OPAT) NSP Quality and

Safety M 5,997 5,200 7,068 CHO 1,104

Unscheduled referrals from community NSP Quality and M 2,580 3,185 3,804 CHO 0

93


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

sources Safety

Outpatient Parenteral Antimicrobial Therapy (OPAT) Re-admission rate %

OP


M ≤5% 4.5% ≤5% HG ≤5%

Community Intervention Teams Referrals by referral source

38,180 43,084 45,432 CHO 6,468

ED / Hospital wards / Units OP Access and Integration

M 25,104 29,719 29,736 CHO 3,948

GP Referral OP Access and Integration

M 8,938 9,621 11,148 CHO 2,160

Community Referral OP Access and Integration

M 2,484 2,723 2,760 CHO 0

OPAT Referral OP Access and Integration

M 1,654 1,021 1,788 CHO 360

GP Out of Hours

No. of contacts with GP Out of Hours Service

NSP Access and Integration

M 1,105,151 1,039,496 1,147,496 National

Physiotherapy

No. of physiotherapy patient referrals OP Access and Integration

M 197,299 199,236 199,236 CHO 25,776

No. of physiotherapy patients seen for a first time assessment

OP Access and Integration

M 162,554 160,488 162,549 CHO 24,570

No. of physiotherapy patients treated in the reporting month (monthly target)


M 34,927 34,605 34,926 CHO 5,232

No. of physiotherapy service face to face contacts/visits


M 726,724 709,764 709,764 CHO 95,076

94


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

Total no. of physiotherapy patients on the assessment waiting list at the end of the reporting period


M 35,429 34,023 34,023 CHO 4,718

No. of physiotherapy patients on the assessment waiting list at the end of the reporting period 0 - ≤ 12 weeks


M No target 21,437 No target CHO No target

No. of physiotherapy patients on the assessment waiting list at the end of the reporting period >12 weeks - ≤ 26 weeks



No. of physiotherapy patients on the assessment waiting list at the end of the reporting period >26 weeks but ≤ 39 weeks



No. of physiotherapy patients on the assessment waiting list at the end of the reporting period >39 weeks but ≤ 52 weeks



No. of physiotherapy patients on the assessment waiting list at the end of the reporting period > 52 weeks



% of new physiotherapy patients seen for assessment within 12 weeks


M 80% 81% 81% CHO 81%

% of physiotherapy patients on waiting list for assessment ≤ 26 weeks


M 80% 84% 84% CHO 84%

% of physiotherapy patients on waiting list for assessment ≤ 39 weeks


M 89% 91% 91% CHO 91%

95


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

% of physiotherapy patients on waiting list for assessment ≤ to 52 weeks


M 93% 95% 95% CHO 95%

Occupational Therapy

No. of occupational therapy service user referrals


M 90,961 94,800 94,800 CHO 11,292

No. of new occupational therapy service users seen for a first assessment


M 90,700 91,740 94,678 CHO 10,489

No. of occupational therapy service users treated (direct and indirect) monthly target


M 20,513 21,803 21,803 CHO 2,398

Total no. of occupational therapy service users on the assessment waiting list at the end of the reporting period


M 30,258 31,220 31,220 CHO 5,246

No. of occupational therapy service users on the assessment waiting list at the end of the reporting period 0 - ≤ 12 weeks



No. of occupational therapy service users on the assessment waiting list at the end of the reporting period >12 weeks - ≤ 26 weeks



No. of occupational therapy service users on the assessment waiting list at the end of the reporting period >26 weeks but ≤ 39 weeks



No. of occupational therapy service users on the assessment waiting list at the end of



96


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

the reporting period >39 weeks but ≤ 52 weeks

No. of occupational therapy service users on the assessment waiting list at the end of the reporting period > 52 weeks



% of new occupational therapy service users seen for assessment within 12 weeks


M 68% 65% 68% CHO 68%

% of occupational therapy service users on waiting list for assessment ≤ 26 weeks


M 54% 54% 54% CHO 54%

% of occupational therapy service users on waiting list for assessment ≤ 39 weeks


M 67% 67% 67% CHO 67%

% of occupational therapy service users on waiting list for assessment ≤ to 52 weeks


M 85% 76% 85% CHO 85%

Primary Care – Speech and Language Therapy

No. of speech and language therapy patient referrals


M 51,763 50,892 50,892 CHO 5,208

Existing speech and language therapy patients seen in the month


M 19,515 19,621 19,514 CHO 2,515

New speech and language therapy patients seen for initial assessment


M 45,631 42,432 45,635 CHO 4,695

Total no. of speech and language therapy patients waiting initial assessment at end of the reporting period


M 13,359 14,236 14,236 CHO 1,585

97


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

Total no. of speech and language therapy patients waiting initial therapy at end of the reporting period


M 8,008 7,939 7,939 CHO 1,694

% of speech and language therapy patients on waiting list for assessment ≤ to 52 weeks


M 100% 96% 100% CHO 100%

% of speech and language therapy patients on waiting list for treatment ≤ to 52 weeks


M 100% 93% 100% CHO 100%

Primary Care – Speech and Language Therapy Service Improvement Initiative

New speech and language therapy patients seen for initial assessment


M 5,659 3,882 3,882 CHO 581

No. of speech and language therapy initial therapy appointments


M 18,940 16,956 16,956 CHO 4,554

No. of speech and language therapy further therapy appointments


M 21,732 20,062 20,062 CHO 1,669

Primary Care – Podiatry Updated 18/1/19

No. of podiatry patient referrals OP Access and Integration

M 10,749 11,184 11,184 CHO 816

Existing podiatry patients seen in the month OP Access and Integration

M 5,656 6,187 6,187 CHO 255

New podiatry patients seen OP Access and Integration

M 6,339 8,856 8,856 CHO 444

98


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

Total no. of podiatry patients on the treatment waiting list at the end of the reporting period


M 4,145 3,654 3,654 CHO 626

No. of podiatry patients on the treatment waiting list at the end of the reporting period 0 - ≤ 12 weeks



No. of podiatry patients on the treatment waiting list at the end of the reporting period >12 weeks - ≤ 26 weeks


M No target 716 No target CHO No target

No. of podiatry patients on the treatment waiting list at the end of the reporting period >26 weeks but ≤ 39 weeks



No. of podiatry patients on the treatment waiting list at the end of the reporting period >39 weeks but ≤ 52 weeks



No. of podiatry patients on the treatment waiting list at the end of the reporting period > 52 weeks



% of podiatry patients on waiting list for treatment ≤ 12 weeks


M 26% 32% 32% CHO 32%



M 43% 52% 52% CHO 52%



M 61% 65% 65% CHO 65%

% of podiatry patients on waiting list for treatment ≤ to 52 weeks


M 77% 75% 77% CHO 77%

99


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

No. of patients with diabetic active foot disease treated in the reporting month

OP Quality and

Safety M 502 552 566 CHO 53

No. of treatment contacts for diabetic active foot disease in the reporting month


M 878 1,077 1,113 CHO 69

Primary Care – Ophthalmology

No. of ophthalmology patient referrals OP Access and Integration

M 28,286 24,888 24,888 CHO 4,344

Existing ophthalmology patients seen in the month


M 5,923 6,080 6,080 CHO 1,151

New ophthalmology patients seen OP Access and Integration

M 25,314 26,232 26,232 CHO 7,584

Total no. of ophthalmology patients on the treatment waiting list at the end of the reporting period


M 20,748 20,203 20,203 CHO 1,380

No. of ophthalmology patients on the treatment waiting list at the end of the reporting period 0 - ≤ 12 weeks



No. of ophthalmology patients on the treatment waiting list at the end of the reporting period >12 weeks - ≤ 26 weeks



No. of ophthalmology patients on the treatment waiting list at the end of the reporting period >26 weeks but ≤ 39 weeks



100


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

No. of ophthalmology patients on the treatment waiting list at the end of the reporting period >39 weeks but ≤ 52 weeks



No. of ophthalmology patients on the treatment waiting list at the end of the reporting period > 52 weeks



% of ophthalmology patients on waiting list for treatment ≤ 12 weeks


M 26% 23% 26% CHO 26%



M 46% 38% 46% CHO 46%



M 58% 49% 58% CHO 58%



M 66% 59% 66% CHO 66%

Primary Care – Audiology

No. of audiology patient referrals OP Access and Integration

M 21,139 20,256 20,256 CHO 2,928

Existing audiology patients seen in the month


M 2,899 2,849 2,899 CHO 237

New audiology patients seen OP Access and Integration

M 17,765 16,512 17,760 CHO 2,080

Total no. of audiology patients on the treatment waiting list at the end of the reporting period


M 14,693 15,088 15,088 CHO 2,387

101


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

No. of audiology patients on the treatment waiting list at the end of the reporting period 0 - ≤ 12 weeks



No. of audiology patients on the treatment waiting list at the end of the reporting period >12 weeks - ≤ 26 weeks



No. of audiology patients on the treatment waiting list at the end of the reporting period >26 weeks but ≤ 39 weeks



No. of audiology patients on the treatment waiting list at the end of the reporting period >39 weeks but ≤ 52 weeks



No. of audiology patients on the treatment waiting list at the end of the reporting period > 52 weeks



% of audiology patients on waiting list for treatment ≤ 12 weeks


M 41% 38% 41% CHO 41%



M 64% 60% 64% CHO 64%



M 78% 75% 78% CHO 78%

% of audiology patients on waiting list for treatment ≤ to 52 weeks


M 88% 87% 88% CHO 88%

National Newborn Hearing Screening Programme

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2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

Total no. and % of eligible babies whose screening was complete by four weeks


Q, 1 Qtr in Arrears

64,027 TBA >95%

National. CHO number baseline to

be established

in 2018

>95%

No. of babies identified with primary permanent childhood hearing impairment referred to audiology services from the screening programme


Q, 1 Qtr in Arrears

90 TBA

CHO 9

TBA

No. and % of babies from screening programme identified with a hearing loss by six months of age

OP Quality and

Safety Q, 1 Qtr in

Arrears

71

TBA

≥80%

CHO

7

TBA

≥80%

Primary Care – Dietetics

No. of dietetic patient referrals OP Access and Integration

M 34,015 34,788 34,788 CHO 2,904

Existing dietetic patients seen in the month OP Access and Integration

M 3,459 3,349 3,459 CHO 357

New dietetic patients seen OP Access and Integration

M 21,873 23,028 21,874 CHO 2,461

Total no. of dietetic patients on the treatment waiting list at the end of the


M 14,241 16,085 16,085 CHO 2,235

103


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

reporting period

No. of dietetic patients on the treatment waiting list at the end of the reporting period 0 - ≤ 12 weeks



No. of dietetic patients on the treatment waiting list at the end of the reporting period >12 weeks - ≤ 26 weeks



No. of dietetic patients on the treatment waiting list at the end of the reporting period >26 weeks but ≤ 39 weeks



No. of dietetic patients on the treatment waiting list at the end of the reporting period >39 weeks but ≤ 52 weeks



No. of dietetic patients on the treatment waiting list at the end of the reporting period > 52 weeks



% of dietetic patients on waiting list for treatment ≤ 12 weeks


M 37% 34% 37% CHO 37%



M 59% 52% 59% CHO 59%



M 71% 62% 71% CHO 71%

% of dietetic patients on waiting list for treatment ≤ to 52 weeks


M 79% 70% 79% CHO 79%

104


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

Primary Care – Psychology

No. of psychology patient referrals OP Access and Integration

M 12,480 12,948 12,948 CHO 1,536

Existing psychology patients seen in the month


M 2,240 2,550 2,550 CHO 201

New psychology patients seen OP Access and Integration

M 13,144 10,884 10,884 CHO 1,824

Total no. of psychology patients on the treatment waiting list at the end of the reporting period


M 7,868 7,919 7,919 CHO 1,016

No. of psychology patients on the treatment waiting list at the end of the reporting period 0 - ≤ 12 weeks



No. of psychology patients on the treatment waiting list at the end of the reporting period >12 weeks - ≤ 26 weeks



No. of psychology patients on the treatment waiting list at the end of the reporting period >26 weeks but ≤ 39 weeks



No. of psychology patients on the treatment waiting list at the end of the reporting period >39 weeks but ≤ 52 weeks



No. of psychology patients on the treatment waiting list at the end of the reporting period > 52 weeks



105


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

% of psychology patients on waiting list for treatment ≤ 12 weeks


M 36% 27% 36% CHO 36%



M 48% 49% 49% CHO 49%



M 62% 64% 64% CHO 64%

% of psychology patients on waiting list for treatment ≤ to 52 weeks


M 81% 75% 81% CHO 81%

Primary Care – Nursing

No. of nursing patient referrals OP Access and Integration

M 139,184 140,832 140,832 CHO 11,232

Existing nursing patients seen in the month OP Access and Integration

M I Mth in Arrears

52,063 49,436 52,063 CHO 4,706

New nursing patients seen OP Access and Integration

M I Mth in Arrears

118,849 134,916 118,849 CHO 2,533

% of new patients accepted onto the nursing caseload and seen within 12 weeks


M I Mth in Arrears

96% 99% 100% CHO 100%

Child Health

% of children reaching 10 months within the reporting period who have had child development health screening on time or

NSP Quality and

Safety M I Mth in

Arrears 95% 93% 95% CHO 95%

106


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

before reaching 10 months of age

% of newborn babies visited by a PHN within 72 hours of discharge from maternity services

NSP Quality and

Safety Q 98% 96% 98% CHO 98%

% of babies breastfed (exclusively and not exclusively) at first PHN visit

NSP Quality and

Safety Q 1 Qtr in

Arrears 58% 56% 58% CHO 58%

% of babies breastfed exclusively at first PHN visit

NSP Quality and

Safety Q 1 Qtr in

Arrears 48% 40% 48% CHO 48%

% of babies breastfed (exclusively and not exclusively) at three month PHN visit

NSP Quality and

Safety Q 1 Qtr in

Arrears 40% 40% 40% CHO 40%

% of babies breastfed exclusively at three month PHN visit

NSP Quality and

Safety Q 1 Qtr in

Arrears 30% 30% 30% CHO 30%

Oral Health Primary Dental Care

No. of new oral health patients in target groups attending for scheduled assessment


M 131,386 139,152 139,152 162,336

CHO 20,820

No. of new oral health patients attending for unscheduled assessment


M 62,081 64,812 64,812 CHO 7,968

% of new oral health patients who commenced treatment within three months of scheduled oral health assessment


M 92%

90%

90% CHO 90%

Orthodontics

107


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

No. of orthodontic patients receiving active treatment at the end of the reporting period


Q 16,431 18,000 18,000 National/

former region

No. and % of orthodontic patients seen for assessment within 6 months


Q 2,483 46%

2,406 45%

2,459 2,406 46%

National/ former region

% of orthodontic patients on the waiting list for assessment ≤ 12 months


Q 100% 95% 100% National/

former region

% of orthodontic patients on the treatment waiting list ≤ two years


Q 75% 58% 75% National/

former region

% of orthodontic patients (grades 4 and 5) on treatment waiting list less than four years


Q 99% 94% 99% National/

former region

No. of orthodontic patients on the assessment waiting list at the end of the reporting period


Q 7,199 8,722 8,722 National/

former region

No. of orthodontic patients (grade 4) on the treatment waiting list at the end of the reporting period


Q 9,566 9,432 9,432 National/

former region

No. of orthodontic patients (grade 5) on the treatment waiting list at the end of the reporting period


Q 8,369 8,426 8,426 National/

former region

108


2018 2018 2019


Target


Area Reporting

Period


Expected Activity



Expected Activity


CHO 5

Reduce the proportion of orthodontic patients (grades 4 and 5) on the treatment waiting list waiting longer than four years % of orthodontic patients (grades 4 and 5) on the treatment waiting list longer than four years


Q <1% 6% <6% National/

former region

Services to persons with Hepatitis C

No. of Health Amendment Act 1996 cardholders who were reviewed REMOVE SHADING NO LONGER NSP

OP Quality and

Safety Q 459 119 340 National 45

109

KPI Social Inclusion Performance Activity / KPI (Wording as per NSP/OP) Target/EA Full Year CHO 5

Number of pharmacies recruited to provide a Pharmacy Needle Exchange Programme 95 15

No of unique individuals attending the Pharmacy Needle Exchange Programme 1,650 324

No. of pharmacy needle exchange packs provided as per the Pharmacy Needle Exchange Programme

No Target

Number of clean needles provided each month as per the Pharmacy Needle Exchange Programme 22,559 4,759

Average no. of clean needles (and accompanying injecting paraphenilia per unique individual each month 14 14

No. of needle / syringe packs returned as per the Pharmacy Needle Exchange Programme 643 130

% of needle / syringe packs returned as per the Pharmacy Needle Exchange Programme 41% 41%

110

KPI’s Palliative Care Palliative Care Target/EA Full Year CHO 5

Access to specialist inpatient bed within seven days during the reporting year 98% 98%

No. accessing specialist inpatient bed within seven days (during the reporting year)

3,809 68

% of patients triaged within one working day of referral (Inpatient Unit) 90% 90%

Access to specialist palliative care services in the community provided within seven days (normal place of residence) 90% 90%

% of patients triaged within one working day of referral (Community) 95% 95%

No. of patients who received specialist palliative care treatment in their normal place of residence in the month 3,405 422

No. of children in the care of the Clinical Nurse Co-ordinator for Children with Life Limiting Conditions (children’s outreach nurse) 280 30

No. of children in the care of the acute specialist paediatric palliative care team (during the reporting month) 97

111

KPI’s Mental Health Key Performance Indicators Service Planning

2019

Reported against NSP

KPI Type Access/ Quality /Access Activity

Report Frequency

KPI Title


Expected Activity

Reported at

National / CHO /

HG Level

CHO5

% of accepted referrals / re-referrals offered first appointment within 12 weeks by General Adult Community Mental Health Team

NSP Quality M 90% CHO 90%

% of accepted referrals / re-referrals offered first appointment and seen within 12 weeks by General Adult Community Mental Health Team


%. of new (including re-referred) General Adult Community Mental Health Team cases offered appointment and DNA in the current month

NSP Access /Activity M < 22% CHO < 22%

% of accepted referrals / re-referrals offered first appointment within 12 weeks by Psychiatry of Later Life Community Mental Health Teams


% of accepted referrals / re-referrals offered first appointment and seen within 12 weeks by Psychiatry of Later Life Community Mental Health Teams


112

%. of new (including re-referred) Later Life Psychiatry Team cases offered appointment and DNA in the current month

NSP Access /Activity M < 3% CHO < 3%

Admissions of children to Child and Adolescent Acute Inpatient Units as a % of the total number of admissions of children to mental health acute inpatient units.

NSP Quality M 75% National N/A

Percentage of Bed days used in HSE Child and Adolescent Acute Inpatient Units as a total of Bed days used by children in mental health acute inpatient units


% of accepted referrals / re-referrals offered first appointment within 12 weeks by Child and Adolescent Community Mental Health Teams


% of accepted referrals / re-referrals offered first appointment and seen within 12 weeks by Child and Adolescent Community Mental Health Teams


%. of new (including re-referred) child/adolescent referrals offered appointment and DNA in the current month

NSP NSP M < 10% CHO < 10%

% of accepted referrals / re-referrals offered first appointment and seen within 12 months by Child and Adolescent Community Mental Health Teams excluding DNAs

NSP NSP M 95% CHO 95%

% of urgent referrals to Child and Adolescent Mental Health Teams responded to within three working days

NSP NSP M New KPI 2019

CHO New KPI

2019

No. of adult referrals seen by mental health services NSP Vol Access /Activity M 28,716 CHO 3,465

No. of admissions to adult acute inpatient units NSP Vol Access /Activity Q in arrears 12,148 CHO 1,244

113

No. of Psychiatry of Later Life referrals seen by mental health services NSP Vol Access /Activity M 8,896 CHO 1,210

No. of CAMHs referrals received by mental health services NSP Vol Access /Activity M 18,128 CHO 1,867

No. of CAMHs referrals seen by mental health services NSP Vol Access /Activity M 10,833 CHO 897

Total No. to be seen for a first appointment at the end of each month. OP Access /Activity M 2,498 CHO 155

Total No. to be seen 0-3 months OP Access /Activity M 1,142 CHO 91

Total No. on waiting list for a first appointment waiting > 3 months OP Access /Activity M 1,356 CHO 64

Total No. on waiting list for a first appointment waiting > 12 months OP Access /Activity M 0 CHO 0

No. of admissions to adult acute inpatient units OP Access /Activity Q in arrears 12,148 CHO 1,244

Median length of stay OP Access /Activity Q in arrears 11 CHO 11

Rate of admissions to adult acute inpatient units per 100,000 population in mental health catchment area

OP Access /Activity Q in arrears 62.9 CHO 64.8

First admission rates to adult acute units (that is, first ever admission), per 100,000 population in mental health catchment area


Acute re-admissions as % of admissions OP Access /Activity Q in arrears 63% CHO 63%

Inpatient re-admission rates to adult acute units per 100,000 population in mental health catchment area


No. of adult acute inpatient beds per 100,000 population in the mental health catchment area


No. of adult involuntary admissions OP Access /Activity Q in arrears 1,918 CHO 202

114

Rate of adult involuntary admissions per 100,000 population in mental health catchment area


Number of General Adult Community Mental Health Teams OP Access M 114 (119 returns)

CHO 11

Number of referrals (including re-referred)received by General Adult Community Mental Health Teams

OP Access /Activity M 43,819 CHO 4,870

Number of Referrals (including re-referred) accepted by General Adult Community Mental Health Teams


No. of new (including re-referred) General Adult Community Mental Health Team cases offered first appointment for the current month (seen and DNA below)


No. of new (including re-referred) General Adult Community Mental Health Team cases seen in the current month


No. of new (including re-referred) General Adult Community Mental Health Team cases offered appointment and DNA in the current month

OP Access /Activity M 6,319 CHO 763

%. of new (including re-referred) General Adult Community Mental Health Team cases offered appointment and DNA in the current month

OP Access /Activity M < 22% CHO < 22%

Number of cases closed/discharged by General Adult Community Mental Health Teams


Number of Psychiatry of Later Life Community Mental Health Teams OP Access M 31 CHO 5

Number of referrals (including re-referred)received by Psychiatry of Later Life Mental Health Teams


115

Number of Referrals (including re-referred) accepted by Psychiatry of Later Life Community Mental Health Teams


No. of new (including re-referred ) Later Life Psychiatry Team cases offered first appointment for the current month (seen and DNA below)


No. of new (including re-referred) Later Life Psychiatry Team cases seen in the current month


No. of new (including re-referred) Later Life Psychiatry cases offered appointment and DNA in the current month

OP Access /Activity M 267 CHO 36

Number of cases closed/discharged by Later Life Psychiatry Community Mental Health Teams


No. of child and adolescent Community Mental Health Teams OP Access M 70 CHO 7

No. of child and adolescent Day Hospital Teams OP Access M 4 CHO 0

No. of Paediatric Liaison Teams OP Access M 3 CHO 0

No. of child / adolescent admissions to HSE child and adolescent mental health inpatient units

OP Access /Activity M 296 CHO N/A

No. of children / adolescents admitted to adult HSE mental health inpatient units OP Access /Activity M 30 National N/A

i). <16 years OP Access /Activity M 0 National N/A

ii). <17 years OP Access /Activity M 0 National N/A

iii). <18 years OP Access /Activity M 30 National N/A

116

No. of child / adolescent referrals (including re-referred) received by mental health services


No. of child / adolescent referrals (including re-referred) accepted by mental health services


No. of new (including re-referred ) CAMHs Team cases offered first appointment for the current month (seen and DNA below)


No. of new (including re-referred) child/adolescent referrals seen in the current month


No. of new (including re-referred) child/adolescent referrals offered appointment and DNA in the current month


No. of cases closed / discharged by CAMHS service OP Access /Activity M 10,454 CHO 1,074

Total No. to be seen for a first appointment by expected wait time at the end of each month.


i) 0-3 months OP Access /Activity M 1,142 CHO 91

ii). 3-6 months OP Access /Activity M 550 CHO 33

iii). 6-9 months OP Access /Activity M 454 CHO 20

iv). 9-12 months OP Access /Activity M 352 CHO 11

v). > 12 months OP Access /Activity M 0 CHO 0

12-15 months OP Access /Activity M 0 CHO 0


117

> 18 months OP Access /Activity M 0 CHO 0











>48 months OP Access /Activity M 0 CHO 0

118

KPI’s Disability Services Performance Activity / KPI (Wording as per NSP/OP) Target/EA Full Year

CHO 5

Safeguarding: (combined KPI's with Older Persons Service) % of Preliminary Screenings for adults aged 65 years and over with an outcome of reasonable grounds for concern that are submitted to the Safeguarding and Protection Teams accompanied by an interim Safeguarding Plan.

100% 100%

Safeguarding: (combined KPI's with Older Persons Service) % of Preliminary Screenings for adults under 65 years with an outcome of reasonable grounds for concern that are submitted to the Safeguarding and Protection Teams accompanied by an interim Safeguarding Plan.

100% 100%

% compliance with regulations following HIQA inspection of Disability Residential Services 80%

No. of requests for assessments of need received for children 5,065 265

% of child assessments completed within the timelines as provided for in the regulations 100% 100%

% of school leavers and Rehabilitation Training (RT) graduates who have been provided with a placement 100% 100%

% of Children's Disability Network Teams established 100% 100%

No. of Children’s disability Network Teams established 80 No target 25

No. of residential places for people with a disability 8,568 886

No. of new emergency places provided to people with a Disability 90

Facilitate the movement of people from congregated to community settings 160 15

No of people with a disability in receipt of work/work-like activity services (ID/Autism and Physical and sensory disability) 2,513 446

No. of people (all disabilities) in receipt of Rehabilitative Training (RT) 2,282 287

119

No. of people with a disability in receipt of other day services (excl. RT and work/ Work-like activities (adult) (ID / Autism and Physical and sensory disability)

22,272 3,483

No of day only respite sessions accessed by people with a disability(ID/Autism and Physical and Sensory Disability) 32622 1,405

No of people with a disability in receipt of respite services (ID/Autism and Physical and Sensory Disability) 6,559 461

No. of overnights (with or without day respite) accessed by people with a disability(ID/Autism and Physical and Sensory Disability) 182,506 13,722

Number of PA Service hours delivered to adults with a physical and / or sensory disability 1,630,000 178,593

No. of adults with a physical and / or sensory disability in receipt of a PA service 2,535 406

No. of Home Support Service Hours delivered to people with a disability (ID/Autism and Physical and Sensory Disability) 3,080,000 386,290

No of people with a disability in receipt of Home Support Services (ID/Autism and Physical and Sensory Disability) 8,094 904

Percentage of "Transforming Lives" priorities Implemented 100% Retired

Percentage of Service improvement priorities implemented 100% Retired

% of CHOs who have established a Residents' Council / Family Forum / Service User Panel or equivalent for Disability Services 100% Retired

% of CHO quality and safety committees in place with responsibilities to include governance of the quality and Safety of HSE provided disability Services who have met in this reporting month

100%

Retired

120

KPI’s Older Persons Services Performance Activity / KPI (Wording as per NSP/OP) Target/EA Full Year CHO 5

Quality

% of CHOs who have established a Residents’ Council / Family Forum / Service User Panel or equivalent for Services for Older People

% of compliance with Regulations following HIQA inspection of HSE direct-provided Older Persons Residential Services 80% N/A

% of CHO Quality and Safety Committees with responsibilities to include governance of the quality and safety of Older Persons' Services who have met in this reporting month

Safeguarding

% of Preliminary Screenings for adults aged 65 years and over with an outcome of reasonable grounds for concern that are submitted to the Safeguarding and Protection Teams accompanied by an interim Safeguarding Plan.

100% 100%

% of Preliminary Screenings for adults under 65 years with an outcome of reasonable grounds for concern that are submitted to the Safeguarding and Protection Teams accompanied by an interim Safeguarding Plan.

100% 100%

Deliver on Service Improvement Priorities

Deliver on Service Improvement Priorities: %of Service improvement priorities implemented

Home Support

No. of Home Support hours provided (excluding provision of hours from Intensive Home Care Packages (IHCPs)) 17,900,000 1,950,000

No. of people in receipt of Home Support (excluding provision from Intensive Home Care Packages(IHCPs)) - each person counted once only 53,182 6,115

Intensive Home Care Packages

Total No. of persons in receipt of an Intensive Home Care Package (IHCP) 235 N/A

% of clients in receipt of an IHCP with a Key Worker Assigned 100% 100%

No. of Home Support hours provided from Intensive Home Care Packages 360,000 N/A

NHSS

121

No. of persons funded under NHSS in long term residential care during the reporting month 23,042 N/A

% of clients with NHSS who are in receipt of Ancillary State Support 13.5% N/A

% of clients who have Common Summary Assessment Report (CSARs) processed within 6 weeks 90% N/A

Public Beds

No. of NHSS Beds in Public Long Stay Units 4,900 511

No. of Short Stay Beds in Public Long Stay Units 1,850 229

% Occupancy of Short Stay Beds to commence Q3 2019 90% 90%

% of population over 65 years in NHSS funded Beds (based on 2016 Census figures) ≤3.5% N/A

Transitional Care Beds

No. of Persons at any given time being supported through transitional care in alternative care settings 1,160 N/A

No. of Persons in acute hospitals approved for transitional care to move to alternative care settings 10,980 N/A

Single Assessment Tool (SAT)

No. of People seeking service who have been assessed using the Single Assessment Tool(SAT)(commencing Q4) 300 N/A

122

KPI’s Health & Wellbeing Key Performance Indicators Service

Planning 2018

Reported against NSP / DOP

KPI Type Access/ Quality /Access

Activity Report Frequency

KPI Title


Expected Activity

Reported at

National / CHO / HG

Level

CHO5

HG5

No. of smokers who received face to face or telephone intensive cessation support from a cessation counsellor

NSP Access /Activity Q-1Q 11,500 CHO/HG/

Nat Quitline

No. of smokers who are receiving online cessation support services NSP Q ?? National

% of smokers on cessation programmes who were quit at four weeks NSP Access /Activity Q-1Q 45% National

No. of unique runners completing a 5k park run DOP Quality M

220,946

CHO/LHO

123

No. of people attending a HSE funded structured community based healthy cooking programme

DOP Access /Activity Q 4,400 CHO

No. of people who have completed a structured patient education programme for type 2 diabetes

NSP Access /Activity M 4,190 CHO 345

% children aged 12 months who have received 3 doses Diphtheria (D3), Pertussis (P3), Tetanus (T3) vaccine Haemophilus influenza type b (Hib3) Polio (Polio3) hepatitis B (HepB3) (6 in 1)

DOP Access /Activity Q-1Q 95% LHO/CHO 95%

% children at 12 months of age who have received two doses of the Pneumococcal Conjugate vaccine (PCV2)


% children at 12 months of age who have received 1 dose of the Meningococcal group C vaccine (MenC1)


124

% children at 12 months of age who have received two doses of the Meningococcal group B vaccine (MenB2)

DOP Q-1Q 95% LHO/CHO 95%

% children at 12 months of age who have received two doses of Rotavirus vaccine (Rota2)


% children aged 24 months who have received 3 doses Diphtheria (D3), Pertussis (P3), Tetanus (T3) vaccine, Haemophilus influenza type b (Hib3), Polio (Polio3), hepatitis B (HepB3) (6 in 1)

NSP Access /Activity Q-1Q 95% LHO/CHO 95%

% children aged 24 months who have received 2 doses Meningococcal C (MenC2) vaccine


% children aged 24 months who have received 1 dose Haemophilus influenza type B (Hib) vaccine


% children aged 24 months who have received 3 doses Pneumococcal Conjugate (PCV3) vaccine


125

% children aged 24 months who have received the Measles, Mumps, Rubella (MMR) vaccine

NSP Access /Activity Q-1Q 95% LHO/CHO 95%

% of children aged 24 months who have received three doses of the Meningococcal group B vaccine (MenB3)


% of children aged 24 months who have received two doses of the Rotavirus vaccine (Rota2)


% children in junior infants who have received 1 dose 4-in-1 vaccine (Diphtheria, Tetanus, Polio, Pertussis)

DOP Access /Activity A 95% LHO/CHO 95%

% children in junior infants who have received 1 dose Measles, Mumps, Rubella (MMR) vaccine


% first year students who have received 1 dose Tetanus, low dose Diphtheria, Acellular Pertussis (Tdap) vaccine


% of first year girls who have received two doses of HPV Vaccine NSP Access /Activity A 85% LHO/CHO 85%

126

% of first year students who have received one dose meningococcal C (MenC) vaccine


% of health care workers who have received seasonal Flu vaccine in the 2018-2019 influenza season (acute hospitals)

NSP Access /Activity A 60% National /

HG 60%

% of health care workers who have received seasonal Flu vaccine in the 2018-2019 influenza season (long term care facilities in the community)

NSP Access /Activity A 60% National

/CHO/LHO 60%

% uptake in Flu vaccine for those aged 65 and older with a medical card or GP visit card

NSP Access /Activity A 75% LHO/CHO 75%

No. of infectious disease (ID) outbreaks notified under the national ID reporting schedule

NSP Access /Activity Q 500 National

No. of individual outbreak associated cases of infectious disease (ID) notified under the national ID reporting schedule

DOP Access /Activity Q 5090 National

127

% of identified TB contacts, for whom screening was indicated, who were screened.

DOP Quality Q-1Q >/=80% National

No. of frontline Staff to complete the eLearning Making Every Contact Count Training in brief intervention

NSP Workforce

Q 1,425 National

No. of frontline Staff to complete the Face to Face Module of the Makine Every Contact Count Training in brief intervention

NSP Workforce Q 284 National

community healthcare - operations plan 2019 · patients and service users, to be more responsive to...

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